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Patient restraint under scrutiny

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With ‘unacceptable’ patient restraint once again the focus of public attention, Helen Mooney highlights gaps in current guidance

Last week it emerged that five vulnerable older people had been ‘inappropriately’ restrained by staff at Northwick Park Hospital in North London.

An inquiry by Harrow PCT found that between October and November 2007 five of the 56 patients on the ward had been tied up.

At the time, three wards including Fletcher ward – the one on which the incidents took place – were being managed by the PCT.

The investigation was launched following a complaint by a patient who was tied to his chair with a bed sheet. The PCT’s investigation concluded that staff shortages and a lack of training had led to the incidents.

It also said that, although the use of restraint while caring for older patients was ‘not automatically wrong as it can protect them from falls’, in these five cases it was ‘inappropriate’.

Staff were found to have restrained patients in a chair or wheelchair, using bed sheets, men’s braces or the integrated wheelchair straps – sometimes for long periods of time.

Sarah Crowther, Harrow PCT chief executive, said: ‘Whereas some form of restraint may be used by nursing staff with an elderly patient to protect him or her from harm, the examples we discovered were unacceptable.’

The report concludes that the PCT’s financial difficulty was a contributory factor, as it had led to reduced training and vacancy freezes, which in turn had resulted in a staff shortage.

Between May and November 2007, even minimum staffing levels were not met and ‘hardly any’ frontline staff were found to have received Protection of Vulnerable Adults (POVA) training.

According to Ms Crowther, ‘internal disciplinary action has been taken and a programme of training has been introduced to ensure that all staff provide the best possible care to vulnerable patients’.

The acute trust, which has now taken back control of the ward in question, confirmed that all of the report’s recommendations had been implemented and ‘the PCT and the hospital trust are confident this inappropriate restraint is no longer happening’.

While few would argue that this latest example was not shocking, the use of restraint appears to be a grey area, in terms of both when it is considered acceptable and how it should be carried out. It could be suggested, for example, that the trust is not wholly to blame due to a lack of central guidance on the issue.

The Department of Health has so far failed to clarify its position on staff training for the restraint of patients, despite a number of similar cases coming to light over recent years.

The need for better training in restraint techniques arose at an inquest in January this year into the death in 2004 of mental health patient Geoffrey Hodgkins. Untrained staff at St James’s Hospital, Portsmouth, restrained Mr Hodgkins for 25 minutes until he turned blue.

In 1998, a national training scheme for dealing with violent patients was recommended after the death of David ‘Rocky’ Bennett, a patient with schizophrenia, who was held face down for almost half an hour by four or five members of staff at Norfolk Mental Health Care NHS Trust.

Following Mr Bennett’s death, the government set up a group called the Management of Violence project, which submitted proposals for an accredited training scheme and updated guidance on restraint to the DH in December 2006.

However, these proposals have still not been implemented.

NT understands that the DH is in discussion with the NHS Counter Fraud and Security Management Service to establish a regulation and accreditation scheme for trainers who instruct staff in dealing with violent patients, which will include restraint techniques.

A DH spokesperson said the government was still ‘considering previous recommendations’ and confirmed that the most up-to-date national guidelines on restraint of patients remain those of NICE published in 2005.

The guidance, targeted at mental health settings, states that restraint should be used as a last resort and that staff dealing with potentially violent patients should receive training in restraint techniques.

The RCN advocates the use of restraint only when a ‘detailed multidisciplinary assessment’ has shown that there would be a serious risk to patient safety if it were not used.

However, nurses often have to solve the ‘dilemma’ of human rights versus appropriate restraint of patients on a day-to-day basis.

Earlier this year, the RCN issued guidance on the issue in a booklet Let’s Talk About Restraint. This week, as part of the RCN’s dignity campaign, the college will launch a Practice Support Network to provide nurses with support and advice on how to deliver care that is ‘compassionate, sensitive and respectful’.

Tracy Paine, chairperson of the RCN’s nurses working with older people forum and co-author of the restraint guidance, said it was vital that trusts look at the patient environment and staff-patient interaction, and the effect these factors have on patients.

‘How you deal with patients who may need to be restrained will be individualised,’ she said. ‘Organisations need to ensure that they have proper risk assessments in place and find out what is causing problems for the patient in the first place.’

She also called for clear national guidance on restraint from the government for all organisations, both NHS and independent.

There are thousands of restraint techniques that staff in both the independent sector and the NHS can be taught. However, types of training have never been evaluated nationally they are not standardised.

It seems that training needs to be regulated and accredited and that acute trusts must ensure that staff are trained properly, staffing numbers are maintained and the patient environment is assessed to avoid future inappropriate restraint.

Ms Paine said trusts should make this matter a priority. ‘Ultimately, patients should be appropriately placed, staffing levels need to be adequate and training needs to be appropriate,’ she said.

When might restraint be used?

Adults can be justifiably restrained in the following circumstances:

  • Displaying behaviour that is putting themselves at risk of harm;

  • Displaying behaviour that is putting others at risk of harm;

  • Requiring treatment by a legal order, for example under the Mental Health Act 2007;

  • Requiring urgent life-saving treatment;

  • Needing to be maintained in secure settings.

Source: RCN (2008) Let’s Talk About Restraint. London: RCN.

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