Michael Bland, BSc (Hons), RN, RSCN, DipHE, PGCE.
Senior Lecturer, University of Central Lancashire, Preston; Project Manager, North West Clinical Practice Benchmarking Group; Benchmarking Facilitator and Coordinator, Preston Acute (NHS) Trust and Preston Primary Care Trust; Chorley & South Ribble (NHS) Trust; and Central Manchester and Manchester Children’s University Hospitals Trust
The use of physical restraint is a frequent nursing intervention in the care of children. Wong (1999) states that it may be used to ensure safety, assist diagnosis or therapeutic procedures, restrict movement or immobilise a body part. Collier and Robinson ’s (1997) study on restraint in children found that it is a much-neglected area of research and is rarely discussed or addressed.
Clinical practice benchmarking is a qualitative initiative that fits into the NHS quality assurance agenda (Bland, 2001) and has been used to develop practice in children’s nursing (Ellis, 2000). The model that is currently used within the North West Clinical Practice Benchmarking Group has been modified and adapted for Essence of Care, a national initiative launched by the Department of Health in Chorley, Lancashire, in February 2001 (DoH, 2001). Benchmarking has been used in the North West since 1994 (Ellis, 1995). Its philosophy is to ‘nationally identify best practice in order to facilitate continuous quality improvement of paediatric care through comparison and sharing’. The philosophy remains unchanged and is rooted in the fundamental principles of Essence of Care (DoH, 2001).
The model follows a logical cycle of development of the benchmark: data collection (scoring), analysis, comparison and sharing (Figure 1). Followed by the formulation of action plans to develop ‘best practice’, this is then re-evaluated by returning to the benchmark score, thus allowing practitioners to map their developments in practice.
The clinical practice benchmark on procedural restraint was developed during a theory module on quality initiatives utilised in health service provisions. This followed a teaching and learning session that explored the benefits of benchmarking on practice development. Bland (2000) undertook a similar exercise with a group of students, considering the fundamental and essential aspects of care (now known as Essence of Care) benchmarks being developed by the Department of Health at the time of publication. As benchmarking activity features in the pre-registration curriculum in all child branch cohorts, the student nurses were able to further expand these principles by developing a benchmark to address children’s nursing issues. They also took account of the fundamental philosophies being developed by the NHS Children’s Taskforce and the United Nation’s (1989) Convention on the Rights of the Child, and the need to respect the views of children and young people (Aynsley-Green, 2001).
The principles of benchmarking can be split into seven phases. The students decided on an area of particular interest and developed a practice- focused outcome (Figure 1, phases 1 and 3). This differs from the Essence of Care benchmarks, which have patient-focused outcomes. A series of factors that allow practice could be measured (phase 4). They chose the factors that were important to the benchmark, and, where possible, attached an evidence base.
The continuum developed was devised to enable participating trusts to measure their own service provision around the benchmarking continuums. Following the collation of a series of scores from the practice areas, a comparison meeting takes place (phase 5). This allows best practice to be identified, allowing each participant to take transferable practice elements from the meeting into their own departments (phase 6), thus developing best practice within their own clinical areas (phase 7).
The nurse involved in the restraint of a child must recognise the child’s developmental needs and ensure that his or her safety, both physical and psychological, is taken into account. The factors listed in Box 1 and Figure 2 should be taken into account to ensure appropriate management of restraint.
These factors were developed by identifying key topic areas to be explored; dependent on the knowledge and experience of the group. Practical knowledge and literature is used to decide on each factor. The evidence base for such factors is then reviewed and the elements of best practice are developed.
A philosophy of partnership is encompassed within this continuum. Family-centred care and parental participation have now become the central tenet of paediatric nursing in the UK (Coyne, 1996). Within family-centred care nursing is carried out in partnership with the child and family. The degree of their participation in this care is a complex and multidimensional concept. For example, when considering consent prior to restraint for a clinical procedure, children should be given informed choices, recognising Gillick competency (the capacity to make an informed choice) and non-Gillick competency (Gillick, 1985). Parents engaged in an equal collaboration expect to be involved in the decision-making process (Brownlea, 1987). Parent participation should be viewed as a philosophy that enables parents to retain total responsibility (Fradd, 1987). Involving the family and the child before restraint for clinical procedures benefits everyone (Stephens et al, 1999). Parents are often best placed to predict the response of their child. Review of the literature acknowledges the benefits of partnership, although the ambiguity of this philosophy (Darbyshire, 1995) and recent concerns of theory overtaking practice (Coleman et al, 2000) are acknowledged.
Nurses have a responsibility to provide appropriate methods of restraint when undertaking procedures, ensuring the child’s safety and reducing unnecessary distress. Stephens et al (1999) describe child restraint during insertion of a nasogastric tube. Members of staff pinned the child down during this procedure. The number of staff was increased until the child was sufficiently immobilised in order for the procedure to be completed; frequently this method required four or five adults to sufficiently restrain the child. This unacceptable method of restraint obviously caused great distress for the child, which increased anxiety for both the child and the family. The stress caused to children, families and staff involved in some methods of restraint is recognised (Stephens et al, 1999).
It is possible to cause minimal distress and increase co-operation. Encouraging parents to participate offers the child a degree of comfort. Holding the child on their lap allows parents to reassure and comfort the child and provide a safer and secure restraint. This method only requires one member of staff to be actively engaged in securing safe restraint (Stephens et al, 1999).
A critical principle in restraint management is the recognition of alternatives to restraint and the competency of nurses to be able to practice them appropriately and effectively. The literature and anecdotal evidence suggests this to be an area of concern for staff, children and their families. Research by Stephens et al (1999) has shown ‘it is often being restrained during procedures rather that any pain involved that children find distressing’. This has highlighted the need to develop a factor that considers an alternative to restraint and provides the means to measure and establish best practice for distracting children during painful procedures.
Distraction by parents and members of the multidisciplinary team using instinctive means such as touch, talking and singing (Stephens et al, 1999), or visual and interactive means, such as pop-up books and bubbles, is also effective for children aged three to six. For distraction to have the desired effect, parents and staff need to work collaboratively. Preparation is essential to ensure trust and reduce the potential anxiety for the child and parents. The Agency for Health Care Policy and Research (1992) has made a series of recommendations on hospitals quality assurance procedures in the management of pain and the use of non-pharmacological alternatives, such as distraction.
Many factors influence the nurse’s decision to restrain a child: the child’s age, urgency of the treatment and the type of procedure to be performed. Knowledge and competence play a crucial role in safe and effective restraint management.
The Health and Safety at Work Act (1974) puts the emphasis on employers to provide information, instruction and training to maintain a safe environment. Trusts are expected to have risk-assessment strategies in place, with particular emphasis on prevention of harm to their patients (RCN, 2000). Implementing a formalised education and training programme around restraint of children may create an environment and culture in which risk and the potential for litigation are reduced and the potential for the safety of the child is maximised.
Accurate documentation plays a vital role in the nursing care of children, both from a legal standpoint and also to prevent confusion between nursing staff over what care has or has not been performed. If information about painful procedures previously performed on a child has been documented, nursing staff can identify any additional interventions or approaches that may be required (Melamed and Siegal, 1975). Wong (1999) states that nurses play an important role in the physical restraint of children. They need to carefully assess the children in their care and apply the nursing process in the use of restraint. If the procedure is documented, including the type of restraint and who was involved, this provides an accurate picture of the method of restraint and the outcome. This may be recalled as valuable information in future situations where restraint may be required.
The next stage
The North West Regional Clinical Practice Benchmarking Group is striving to develop practice in three clinical arenas: paediatric care, neonatal care and hospital play and associated therapies. Having completed this work on a benchmark in procedural restraint and provided an evidence base to justify the best practice statements, this benchmark was presented formally to the North West Clinical Practice Bench-marking Group for consideration for further development. This was met with a positive response, and the expressed wish of the group to take this work forward. It is expected that this benchmark will be utilised as a tool to identify best practice in procedural restraint, which in turn will provide the opportunity for practice to develop in 33 member units across the North West of England.
In the light of the launch of the Essence of Care initiative, the need to integrate the views and opinions of children and parents is acknowledged. This is a critical element of Essence of Care and is currently being explored within the North West group. Further exploratory work with some of the existing child and family focus groups in participating member trusts in the North West is planned to further enhance the validity of this benchmark and lead to the development of an integrative approach to best practice. Benchmarking must be inclusive with the target group (children) for it to be purposeful, current and meaningful.
Encouraging students to participate in the benchmarking process is valuable. Students are undertaking education and training in evidence-based practice, have a broad range of clinical experiences and are able to critically reflect and evaluate children’s nursing interventions. The Essence of Care culture is one of sharing and comparing best practice. Students need to be permitted and encouraged to participate in this process at every level to empower them to implement best practice over the coming years.
Within the Essence of Care framework, the patient remains central and should be included in and consulted throughout the process. Children have the right to receive the most effective, efficient and economic care possible and thus formulating a benchmark such as this ensures that best practice is developed.
The authors would like to thank all the students on the 10/98 Child Branch Cohort at the University of Central Lancashire
The Children Act, 1989. London: The Stationery Office.
The Health and Safety at Work Act 1974. London: The Stationery Office.
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