Having to break a child’s trust by overpowering them to perform a necessary but painful procedure can be upsetting for nurses, says Student Nursing Times editor Desiree Deighton
I first witnessed – and unknowingly offered to assist with – the restraint of a child during cannulation, when I was faced with a screaming toddler, frantic parents and urgently instructed by the doctor to “grab a leg and keep them still!”
Seeing this happen frequently to facilitate anaesthesia, cannulation, blood tests, administration of medication and insertion of nasogastric tubes, in various settings, meant that over time the experience of it became less shocking for me.
However, when prompted to think about an issue that we had felt uncomfortable with for our research module, it immediately came to mind.
Invasive clinical procedures in particular can cause pain and distress for the child, which can create a fear of health professionals and have a detrimental psychological impact. Pre-procedure play therapy is promoted to reduce these risks and improve compliance of children.
Some play therapists are outstanding in their preparation for children to undergo procedures – particularly in long-term conditions where ‘Beads of Courage’, playing with Barbie-sized versions of machines and distraction walls are an integral part of care.
However, play therapists are usually employed during daytime hours, which means that on their days off and during nights shifts the nurse is left to do their best at preparation, without the underlying expertise. Even the best efforts cannot guarantee that the child will accept the procedure willingly and not require restraint.
This is particularly significant in acute medical settings where time can mean the difference between life and death, and the child’s consent is not required for the professionals to make decisions in the child’s ‘best interests’.
The terminology of restraint has historically been used interchangeably, including positive handling, facilitated-tucking, restriction, positioning, forced immobilization and therapeutic holding. Much research has been carried out based on the inconsistent use of terminology, and in absence of National Institute for Health and Care Excellence guidelines, The Royal College of Nursing defined the difference between simply ‘holding’ the child securely and the use of full ‘restraint’; described as complete overpowering of the child used only as a last resort.
The guidelines also promoted involving parents in the ‘holding’ of their child during procedures, which has since been proven to reduce distress for all involved, particularly if the child is held upright as opposed to the traditional supine position.
Psychiatric and learning disability settings offer their staff clear guidance and training on restraint – including the need to document, debrief and audit when used. However, pediatric hospital policies are inconsistent across trusts and some individual departments have their own specific child restraint policies and procedures, such as A&E settings.
Due to the lack of consistent pediatric training across hospitals in the UK, many students and nurses are at heightened risk of causing harm to a child through unsafe technique. This is an ethical dilemma considering the Nursing and Midwifery Council’s code of conduct, which defines how the nurse should not cause maleficence and advocate for their patients.
Children under 16 years of age require individual assessment to determine if they are ‘Gillick competent’, using the Fraser Guidelines to explore whether they have the intelligence and understanding to fully appreciate what is involved in their treatment or non-treatment.
Adolescents with long-term conditions are more likely to be listened to about treatment decisions, however those under 16 are often presumed incapacitated due to illness or anxiety of the new environment. Studies have also found children aged four years or under at greatest risk of restraint for procedures.
To restrain a child is not a decision to be made lightly, and knowledge of the correct procedures to follow and techniques to implement are desired by nurses, but not widely available.
Having to break a child’s trust by overpowering them to inflict a necessary but painful procedure, is incredibly upsetting for nurses. I am making it my mission to spread the word about the Royal College of Nursing’s guidelines in settings and learn play therapy techniques that will help me to give my young patients reassurance and safety during an extraordinarily stressful time.