NUMBER 1070 • 24 OCTOBER • restrained
In care settings in general, particular concerns have been expressed about physical intervention techniques that depend on inflicting pain upon the person being restrained for their effectiveness (Baker & Allen, 2001). These concerns have related to one approach in particular, Control and Restraint (C&R), that originated in the UK prison service but that was then cascaded into a whole variety of care settings, including services for children. Its use became particularly prevalent in National Health Service settings. C&R had its origins in the martial arts and utilised a number of procedures (known as “locks”) that caused pain via the abnormal rotation of the joints; it also employed a number of “breakaway” procedures, designed to enable carers to escape from grabs and holds, that were dependent on inflicting pain for their effectiveness. A survey by the Standing Nursing and Midwifery Advisory Council (Royal College of Nursing, 1999a) indicated that 27% of respondents stated that they had been injured while being trained in C&R procedures; 11% of respondents also indicated that service users had been injured on the last occasion that they had applied C&R in practice. The equivalent injury rate for staff was 19%. Not surprisingly, the ethics of using such combative approaches within any care setting have been severely questioned.
Given the risks associated with intrusive restraint procedures, there is an alarming lack of research concerning their use and efficacy. This is a particular worry given the proliferation of organisations offering training in this area; the British Institute of Learning Disabilities (2001), for example, listed over 70 such organisations. As well as being small in volume, the research literature is beset with methodological issues (McDonnell & Sturmey, 1993; Baker & Bissmire, 2000). Allen (2001) reviewed a total of 45 papers covering a variety of client groups. The review summarised findings of the direct effects of training (e.g. the impact upon participants of such variables as confidence and knowledge levels) and indirect effects (e.g. the impact on the use of physical restraint). Mental health services were the focus of the majority of studies followed by learning disability services. C&R was the most researched approach, featuring in 22% of the papers reviewed. Therapeutic Crisis Intervention, a North American model designed for use with children, Positive Behaviour Management (PBM) and Studio III (both of which were designed in the United Kingdom for use in services for people with learning disabilities) each made up 12% of the reviewed studies. The remainder were mainly comprised of individually specific models.
The review concluded that training staff in physical interventions could have both positive and negative outcomes on both direct and indirect effects of training. Direct effects included trained staff being more knowledgeable than untrained, being more confident, and able to successfully learn the interventions taught. Indirect effects included reduced rates of restraint use, lower rates of behavioural incidents, and lower rates of injury to both staff and service users. These results were not consistently achieved, however, and some studies reported trends in the opposite direction.
Given the apparent common usage of restraint in children’s services, the particular absence of data on the use of physical interventions with children and young people is a major concern. Allen (2001) found only four published studies in this area (Titus, 1989; Bell & Mollison, 1995; Bell & Stark, 1998; Nunno, Holden, & Leidy, 2003). Although applying robust research designs to this topic poses many difficulties, the lack of trial-derived data is completely unacceptable given the intrusiveness and risks associated with the procedures concerned (Sailas & Fenton, 1999).
STEVE KILLICK and DAVID ALLEN
Killick, S., and Allen, D. (2005). Training Staff in an Adolescent Inpatient Psychiatric Unit in Positive Approaches to Managing Aggressive and Harmful Behaviour: Does it Improve Confidence and Knowledge? In Child Care in Practice. (Vol) . 11 (3)
pp. 324 – 325