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Don't hold back on restraint

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VOL: 97, ISSUE: 48, PAGE NO: 38

Eddie Orme, BSc Community Health Nursing (Learning Disability), RNMH, is project manager, drugs counselling service, Simpson House, Edinburgh

As a community learning disability nurse, I once visited a middle-aged man with Down's syndrome who was living at home with his elderly mother. She had cared for him throughout his life, but as she got older she became less able to help her son meet his various needs.

As a community learning disability nurse, I once visited a middle-aged man with Down's syndrome who was living at home with his elderly mother. She had cared for him throughout his life, but as she got older she became less able to help her son meet his various needs.

To show her gratitude for my 'help', she concluded the visit with an offer of tea and scones. She and her son are engaging people and the experience was thoroughly rewarding - not only because I had an excuse to abandon my diet.

This anecdote probably conforms with the stereotypical image of the day-to-day work of the community learning disability nurse and I offer it primarily as a juxtaposition to the central theme of this article, which is the less endearing subject of physical restraint.

In contrast to the scenario described above, I have also found myself in various community care settings where residents have presented with violent or aggressive behaviour. Such unwelcome conduct is usually described euphemistically as 'challenging behaviour'. This is a hopelessly inadequate and somewhat sanitised term, as is the more sterile descriptor 'interactional challenge' which is currently being mooted as its successor.

When faced with 'challenging behaviour' - let's be honest, violence and aggression - I have had to resort to the use of physical restraint. In the space of a day, my role can change from compassionate carer to state-registered bouncer - but it is all part of the job.

Reflecting on the past 25 years, I like to think that I have done my bit to improve the lives of those I have met and cared for. Nevertheless, much of my working life has been spent dealing with what might be described as the less savoury aspects of nursing in this field and I have long been puzzled by the general unwillingness and lack of honesty when discussing such issues.

Violence and aggression can, after all, have a serious impact on the quality of life of those sharing accommodation with the 'challenging' person and, ultimately, on that individual. As in the rest of our society, it is usually, though not invariably, men who use violence as a means of resolution.

As a nurse and professional in the field of learning disabilities, I am not advocating a 'bovver boot' mentality. However, I do have growing concerns about the increasing number of independent organisations that offer a service to people with a learning disability but seem ill-prepared to address the real dangers presented by clients who use violence.

I should stress that not all people with a learning disability are violent. Some are violent on occasion for various reasons and it follows that some people with a learning disability are occasionally violent. The question remains: how do we respond to such behaviour?

Training and support
Many contemporary community care settings seem to be staffed by unqualified carers. In fairness to them, most seem to provide decent care. Equally, however, many of these staff appear to have had little or no practical experience, particularly in managing aggression.

Alarmingly, most do not appear to have had any training or preparation to manage such situations, whether before or after taking up their posts. As Churchill (1999) concludes: 'The residential care workforce as a whole may be characterised as female, part-time, poorly paid and very poorly qualified.'

To a degree, this lack of training and experience is something of an irrelevance as most organisations operate a policy of 'no restraint'. On more than one occasion, during visits to settings managed by different organisations, care staff have told me that they are not allowed to use physical restraint. And this policy is adhered to even though the staff and other clients may be subjected to violent behaviour on a routine basis. The message is clear: using restraint is 'negative' and 'punitive', ergo it has no place in any caring service.

But why should this be? Physically restraining a client would seem to be anathema to the caring role and my preference would always be for the scenario with which I began this article: bad for the waistline, but altogether more pleasant and likely to be infinitely healthier than confronting violence and aggression.

I believe, however, that topics such as physical restraint are avoided, largely as a consequence of a confused understanding of the issue of individual rights. The person presenting with violent behaviour often appears to have 'rights' that supersede those of everyone else sharing the same environment, including other people with a learning disability.

Responsibility for individual actions is rarely mentioned. It is as though an unspoken rule exists: 'He has a learning disability therefore it is not really his fault.' Examined more closely, this is a patronising and paternalistic attitude.

Physical restraint is not something to be used lightly and needs to be used in conjunction with clear guidelines and training. It is not the only appropriate response either. I would argue, however, that it is as valid, if not more so, than the long-term use of potentially harmful medication.

As McShane (2000) pointed out, the same rationale applies to caring for patients with dementia: 'Drugs are not the mainstay for treating behavioural problems in dementia; non-pharmacological strategies should be tried first.'

Minimising distress
It is often forgotten that when a person is behaving in a violent or aggressive manner, he or she is in a state of distress. In my experience external control, with physical restraint perhaps the ultimate example of this, often brings the speediest conclusion and comfort to the aggressive individual.

Underlying mental health problems, and more rarely organic factors, can precipitate violent behaviour, as can the many frustrations encountered by people with a learning disability, such as communication difficulties. Again, however, the issue is not what causes such behaviour but how we respond when faced with the violence.

If the problem is one of a behavioural nature, like most behaviours it is learned. And if it remains unchecked it will almost certainly become worse. As a result, a familiar pattern will evolve: the behaviour will become intolerable and the person will be labelled 'unmanageable'.

The regrettable conclusion of such a pattern is that the client risks being removed from the existing care setting to a more secure or custodial environment.

Paradoxically, by embracing ill-founded but well-intentioned concepts of the individual's 'rights' we ultimately do that person a disservice. The client is forced to leave the community where he or she enjoys a life of choice and wider freedom to live in an environment in which this will almost certainly not be the case.

The maxim 'cruel to be kind' has undoubtedly led to all manner of loose interpretations in the past and the use of any physical intervention always carries the risk of abuse. With vigilance, however, the properly planned, implemented and monitored use of physical restraint - when necessary - can be a valuable factor in supporting clients in community settings. Surely this is the ultimate aim.

I am not proposing that we should do so with no regard for an individual's rights. However, the wonderful thing about rights is that we all have them - including the people being assaulted.

Unpalatable or not, restraint is likely to be a necessary part of the carers' role at some time, a view apparently endorsed in a review by the Scottish Executive (2000). Its report states: 'Joint policies on using restraint and managing aggression should be in place, supported by training. These policies should also be constantly monitored.'

Community learning disability nurses do more than restrain people between enjoying tea and scones with their clients. As the plethora of independent care agencies flourishes, they will have an increasingly crucial role in educating community-based residential staff on all issues involved in care, including physical restraint.

Managing violence and aggression through the use of physical restraint is a subject we cannot afford to ignore, as the concluding quote from the Scottish Office (1996) statement on good practice suggests: 'The biggest danger lies in the failure of an organisation to recognise the management of violence as a complex and technical issue which requires specific attention at all organisational levels.'

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