Teaching physical skills to psychiatric
nurses: Towards better practice
Andrew
McDonnell
Director of Studio3 Training Systems,
32 Gay St,
Bath,
U.K.
www.studio3.org
Associate Director of Nursing,
Nottinghamshire Healthcare,
NHS Trust. Duncan MacMillan House,
Nottingham, NG3 6AA.
Paper presented at the 7th European Mental Health
Nursing Conference: Copenhagen: 15-16th February 2002.
Introduction
Many
nurses may be exposed to violent behaviour in their day to day work
(Health Services Advisory Committee, 1987). In response to this in
the United Kingdom there exists a wide range of training which includes
the physical management of such behaviours (Patterson & Leadbetter,
1999). It is not uncommon for training to contain physical management
strategies, this is particularly concerning as
the rationale for teaching such skills are relatively unclear
(McDonnell & Sturmey, 1993). This paper will attempt to briefly
review the issues surrounding training in the physical management
of violence.
Problems
of definition
Control
and restraint is an expression widely used in the nursing profession.
Control & Restraint (C&R) training comprises of a collection
of physical techniques apparently derived
from the 'martial arts' of Aikido in 1979 (Gilbert, 1988).
At present there are at least three different training systems
which use the expression 'C & R' Patterson & Leadbetter, 1999).
These include approaches used in the Prison services, so called 'Care
and Responsibility' training used in at least one of the Special Hospitals
and Control and Restraint (General services) which has been described
as a modified version of 'C & R' for Health and Social Services
in the U.K. It is unfortunate that the terms control and restraint
and care and responsibility have the same initials. It is even more
concerning if staff are unable to define the term. In a recent survey
a significant proportion of nursing staff reported a wide range of
definitions of the term ‘control and restraint’. (McDonnell &
Gallon, 2002a). Some definitions tend to focus on physical management
strategies, others tend to emphasize de-escalation strategies.
Training systems have been reported in the literature which
have been developed outside of the 'C & R' system. These include SCIP (Strategies for Crisis Prevention
and Intervention) approach (Baker & Bismire, 2000) and the Studio3 system (McDonnell, 1997). It
would appear that there are differing schools of thought within the
‘C & R’ community. One definition which may be useful to consider
may be to use the term traditional and progressive ‘C & R’. Progressive
C & R would be regarded as avoiding ‘high risk’ physical management
techniques and specifying a hierarchy of training. Whereas more traditional
methods of C & R are typified by training in physical management
that is broad based and tends to use a ‘kitchen sink’ approach (teaching
for as many situations as possible). If the distinction between general services
‘C & R’ and more traditional systems of ‘C & R’ is a valid
one, it could be cogently argued that this system should use a new
name which would clearly delineate it from other systems. Similarly,
statements such as ‘care and responsibility is not the same as control
and restraint’ can be confusing, both to practitioners and academics.
The expression ‘control and restraint’ is used as a collective
term. (The Mental Health Act Code of practice appears to use the term
in this generic manner). Tarbuck, (1992) in an article use the expression
in a variety of different senses. Indeed, the term is so widely used
that as a construct it has almost achieved the status of ‘reification’
(that is, ‘control and restraint’ is now viewed as a specific construct).
So, what is in a name? The ambiguity created by the expression has
led to difficulties both for clinicians and researchers. The authors
experienced this at first hand when a member of staff in a secure
facility stated that ‘I used control and restraint to calm the person
down’. It almost begs the questions, which type? Which school of thought?
Which physical techniques?
What are breakaway skills ?
The expression breakaway skills is widely in usage and usually
refers to a collection of physical techniques which can enable staff
to break away from grabs and/or holds. Gournay (2001) in a survey
of 839 U.K psychiatric nurses reported that 84.5% of the sample had
received training in breakaway techniques. This is a worrying figure
as the survey did not define the physical techniques taught to staff.
Breakaway skills are ‘normally’, taught as part of a syllabus, however, it is difficult
to ascertain whether such skills are being disseminated in a uniform
and consistent manner. It is extremely concerning that there can be
subtle differences between such skills when they are examined from
a bio-mechanical perspective. Two almost identical movements in appearance
can lead to completely different outcomes for a service user. A good
example of this involves teaching staff to break a simple hand grip.
Some staff are taught to 'find the gap' by extricating their wrist
against the junction of the thumb and forefinger. Others are taught
to rotate their wrist in such a manner that pressure (and considerable)
pain is applied to the thumb joint.
This example also illustrates that physical management strategies
need to be placed in context. It is considered reasonably valid to
assume that the vast majority of human communication is predominantly
non verbal in nature (Argyle, 1988). Therefore, even when a person
is responding to a crisis situation they are communicating a message
to the service user. The obvious option when a person grabs a nurses
wrist, is for the nurse to find out what the person wants. When the
first author recommended such a strategy on a recent training course,
he was told quite clearly by one nurse (who appeared to be in a minority)
that such a method was 'sissy and soft'.
Staff are sometimes taught to resist movements as opposed
to quite literally 'going with flow'. There is a useful comparison
with the Tidal analogy (Barker, 2000) advocated by Professor Barker.
If we attempt to stop fast moving water the energy required is enormous.
However, if we move with the current we can eventually gain some form
of control over the situation. Many physical management techniques
can require a considerable degree of force and momentum. This does
not mean that a nurse should allow themselves to be strangled in situations.
However, Isaac Newton’s principles of motion state that 'for every
action there is an equal and opposite reaction'. When a member of
staff quite literally breaks away from a situation they will have
an impact on the person who attacked them. Clearly, it is not just
a question of carrying out a technique or physical trick, (A physical
product), but, how such a method is used in conjunction with other
skills. (A physical process).
What
is the purpose of teaching physical skills ?
Research
has been conducted in the psychiatric field which indicates that staff
training in behaviour management strategies can reduce rates of assaultive
behaviour and lower levels of injury to staff and service users in
psychiatric settings (Gertz, 1980; Infantino & Musingo, 1985;
Mortimer, 1995). Great care should be taken when examining the outcomes
of these studies. The lack of adequate control groups and follow up
data are extremely worrying. To date it is difficult to find convincing
staff training studies in this area (Allen, 2001)
Given,
the paucity of research data, what is the rationale for teaching staff
physical management skills? On the surface this would appear to be
an obvious question with a clear answer. However, it is difficult
to clearly understand the rationale. Are physical skills being taught
to literally teach people to 'get out' of situations. Numerous poorly
defined physical skills are taught on training courses. If an individual
is taught to release themselves from a choke hold, is there evidence
how successful this would be in a 'real life' situation. It appears
that many training courses offer a menu of physical techniques which
presumably course participants are supposed to remember. We can find
no hard evidence about the usage and effectiveness of techniques.
Indeed it has been the authors experience that few staff actually
use the physical techniques on a regular basis (McDonnell & Gallon,
2002b)It is more likely that physical skills are being taught to improve
the confidence of staff (McDonnell, 1997; Allen, 2001). In this instance
it is hoped that nurses who perceive themselves as capable of physically
managing a crisis situation will be more likely to attempt defusion
strategies. Unfortunately, the opposite may also be true. Staff who
are confident in physically managing a situation may be more likely
to use their physical skills. To date there is little hard evidence
for either hypothesis.
Is C & R a form
of self defence training ?
McDonnell, McEvoy & Dearden, (1994) suggested that there
are similarities between self defence training and a broad range of
training courses used in the Health Service. C & R systems could
be viewed in this manner. There appears to be a syllabus of 'set moves'
a formal assessment and grading system, regular 'refresher' training,
and a hierarchy of competence of instructors. There are of course
concerns with such a similarity. First, self defence training is concerned
primarily with the safety of the person who is being attacked. The
expression 'mind over matter' has been applied to these situations.
'I don't mind what I do to the person because they do not matter'
.In caring environments the relationship with the service user is
of paramount concern. Therefore, protection of the service user and
the person are both equally of concern to service providers. We are
sure that many instructors in ‘C & R’ systems do not consider
that they teach a martial system. However, it is difficult to see
arguments that demonstrate that there is a difference.
Anecdotal evidence suggests that a number senior instructors
in ‘C & R’ have some form of martial arts qualification. The authors
do not make a case for the pro’s and ‘con’s’ of such qualifications.
It is hard to believe that the respective martial arts knowledge of
these instructors has not influenced the culture of ‘C & R’ systems
Is
training in physical management 'high risk'.
Nursing
staff may encounter violence in the workplace, however, they may also
encounter violence whilst attending training courses. Gournay (2001)
reported 18.8% of nursing staff reported that they received injuries
whilst participating on training course, with ‘one in six of
these requiring some medical attention’ (p41). Care should be taken
when interpreting this survey for several reasons: First, it is debatable
whether a postal survey is truly representative of nursing staff throughout
the U.K. Second, we have no way of interpreting what the respondents
classified as an injury. Therefore, we cannot accurately understand
the topography of these injuries. It would be useful to separate tissue
damage from non tissue damage. Given,
these reservations it is concerning that staff may actually be more
at risk of injury on a training course than in the workplace.
Physical
Restraint
Physical
restraint has been defined as:
'
actions or procedures which are designed to limit or suppress movement
or mobility'
(p100) (Harris, 1996).
It
is the anecdotal experience of the authors that physical restraint
is often defined by staff as the use of specific physical techniques,
such as floor or bed restraint. Clearly, the expression as defined
above is much broader than a specific technique. If a person is prevented
from leaving an acute admission ward by a nurse physically holding
that person, this clearly a form of physical restraint. This has implications
for nurses who are expected to record instances of restraint
The
physical restraint of people who present a danger to themselves or
others, may well be socially undesirable but at times a necessity
(McDonnell, 2000). Discussion about restraint techniques is not a
recent event. There are descriptions of ‘floor restraint’ methods
taught to psychiatric nurses in North America which appear to pre-date
the development of ‘C & R’ systems in the U.K.(Lion, Levenberg
& Strang, 1972; Lefensky, De Palma & Lociercero, 1978).
The
vast majority of training systems in the U.K appear to use variations
of so called 'floor restraint' methods. The etiology of these methods
are difficult to trace. There are methods described in the literature
which date to the early 1970s. Recent concerns about 'positional asphyxia'
where an individual may have their respiration compromoised leading
to hypoxia and cardiac difficulties (Reay, Fligner, Stilwell and Arnold,
1992) has led to fears that specific postures can contribute to sudden
death. 'Face down' postures would appear to be associated with the
risk of respiratory problems. Anecdotal evidence suggests that rapid
tranquilization often occurs with an individual in such a posture.
Recently,
some authors have tried to argue that non aversive restraint methods
can be developed for staff who work within the learning disability
field. (Allen, 2001, McDonnell, 2002)).
Stirling & McHugh, (1997) described a floor restraint method
as 'natural therapeutic holding' as an alternative to 'Control &
Restraint' but, as in the case of previous papers the description
of the restraint method was vague and uncontrolled descriptive statistics
of therapeutic outcomes were reported. This reliance on anecdotal
and poorly controlled studies is concerning especially as there have
been a growing number of fatalities at the hands of practitioners
attempting to use physical restraint. (Breakwell, 1997).
Towards better practice?
The
evidence for best practice would appear to be primarily anecdotal
in nature. The remainder of this paper will indicate areas where trainers
who teach physical interventions need to consider in their every day
practice.
Teach physical skills for high frequency behaviours
If
trainers in physical management techniques wish to reduce the number
of skills they teach, these must vary according to the clinical area.
A person may have their hair pulled in an older adults setting whilst
they are attempting to dress an individual. This would be very different
from an assault by a physically healthy young male in a public area.
In a recent study it was found that there were differences in the
frequency and nature of assaults on acute psychiatric wards when compared
with learning disability services (McDonnell & Gallon, 2000b).
Teaching physical management techniques for high frequency occurrences
would appear to offer a sensible rationale. There is also an implication
that this would lead to more ‘bespoke’ training for nursing staff.
Presumably the physical management curriculum would have to reflect
the varying manifestations of aggressive behaviours demonstrated by
differing psychiatric populations
Remember the scared staff principle
The
'scared staff rule' implies that people who are confronted with an
angry and physically aggressive individual will be fearful and extremely
tense. Therefore, when staff are taught so called 'breakaway' procedures,
it can be predicted that they may carry out a movement with more force
and speed than they would under calm 'practice conditions'. Therefore,
when assessing the effectiveness of a physical technique the movement
should be examined under conditions where it is conducted very rapidly.
Avoid
locking procedures
The
abnormal rotation of joints and other forms of hyperflexion are often
referred to as arm or wrist locks. Literally, a person may be unable
to move without having quite severe pain inflicted on them. A common
argument of physical interventions trainers is that 'a lock only hurts
is the person moves'. Whilst, this may initially sound quite plausible
the argument unravels relatively easily. First,
it is difficult to hold a person who is struggling violently
using such methods without psychiatric nurses 'willfully' inflicting
pain on the person. Second, in the martial arts fraternity it is generally
considered that these techniques are extremely easy to teach relative
novices to apply rapidly. The major problem is teaching people to
apply such methods using minimum force (Allison, 2002). Finally, there
is no avoiding the issue that these techniques will often involve
inflicting pain on people. It is concerning that
There
are serious issues about the infliction of pain on individuals. The
Royal
College
of Psychiatrists (1995) has been particularly scathing about such
procedures:
'There
is no evidence in the literature that the use of Control and restraint
has been examined to determine its relevance.
Its role becomes particularly problematic and hazardous where
the patients perception of pain is altered (as might occur with learning
disability, autism or various psychiatric states' p6)
If a person is extremely
angry their perceptions of events can be extremely distorted (Novaco,
1978). There is always the risk that the intentional or unintentional
infliction of pain on a distressed individual may already exacerbate
a difficult situation.
Avoid
teaching ‘face down’ holds
Prone
(face down) restraint postures have been linked to a number of sudden
deaths in the United States (Conneticut Courant 1999; ). Although
the reasons for these deaths may be quite complex (Patterson. Leadbetter
& McComish, 1998). Surprisingly, it has been suggested that such
positions should be avoided but, not necessarily banned (Patterson & Leadbetter, 1999) 'face down
restraint in the prone position should represent the maximal permissable
intervention in terms of restraint'. (pp136). These authors typify
an approach which is based on a 'worst case scenario'. Typically,
advice suggests avoiding procedures rather than banning them because
of the possibility that in extreme circumstances such methods may
have to be used. There are several difficulties with this argument.
First, it is debatable whether training can provide solutions to extreme
situations. The recent tragic death of a local counsellor in the UK
who was attacked with a 'samurai sword', illustrates the pitfalls
of this approach. Would we really consider teaching public officials
how to disarm such lethal weapons as an option ? Indeed, how much
training would be required to train people to an adequate and safe
standard ? Second, in secure environments there is a tendency for
staff to expected to deal with extreme violence. The involvement of
the police would appear to be a relative rarity. This can create serious
conflicts of interest for nursing staff.
Consider
the relationship between human movement and emotion
Human
movement and human emotion are integrally linked. In the animal rapid
movements communicate threat. Similarly, postures can also indicate
warning signs of impending attack. The debate about the connection
between
the
expression of emotion in man is not recent. Charles Darwin began to
discuss such relationships in the late nineteenth century. Animals
communicate using non verbal cues. (Argyle, 1988). It is important
to understand that the movements taught to nursing staff may have
an emotional impact on themselves and service users.
The
relationship between the nurse and the service user is important in
maintaining a non violent culture. Negative interactions can lead
to service user violence (Whittington & Wykes, 1994). When training
staff in physical interventions much more attention should be placed
on the analysis of physical techniques and their effect on both the
staff member and service user. Literally, what emotions are being
conveyed to the service users and in addition what emotionally is
the physical technique conveying to the member of staff. It is the
authors experience that locking procedures may have negative emotional
connotation’s for nurses (‘I really don’t like doing this’) or in
some circumstances they make a member of staff feel powerful and in
control. It is also worth mentioning that some service users may have
been victims of sexual abuse. Certain, restraint
(particularly, ‘face down’ methods) postures may evoke powerful emotional
responses.
Teach
techniques that are highly socially valid.
The
social validity of behavioural interventions was first highlighted
by researchers in the learning disabilities field (Wolf, 1978). The
construct highlights the views of consumers and society to interventions.
Physical interventions, especially those involving restraint are often
low in indices of social validity. McDonnell, Sturmey & Dearden,
(1993) compared the views of people without experience of working
in residential care to rate three physical restraint methods. Prone,
supine and chair methods. Both prone and supine restraint methods
were rated as less socially acceptable than the chair method. It is
important to note that people were not asked to rate the acceptability
of not restraining the person at all. Further studies have replicated
these findings with professional groups (McDonnell & Sturmey,
2000) and service users with learning disabilities (Cunningham, McDonnell,
Sturmey & Easton,2002). Similar studies are required in the field
of psychiatric nursing. The views of service users (and front-line
staff both require to be examined. Indeed, it would be interesting
to evaluate many of the so called 'breakaway methods by asking service
user, staff and members of the public to rate their acceptability.
In conclusion social validity is a useful tool for discriminating
between physical restraint methods. In the absence of clear outcome
data on safety and effectiveness the social validity of such methods
will be of increasing importance.
General Conclusions
There
are a number of concerns expressed in this paper. First, the lack
of an appropriate definition of the term ‘C & R’ hampers both
research and clinical practice. Second, the empirical basis for physical
management training is at best ‘crude and predominantly anecdotal
in nature. Third, the principles espoused in this paper could be adopted
by trainers in a broad range of training systems that teach physical
management strategies. Finally, nurses and policy makers need to examine the issues
in detail. It is no use making sweeping statements that such as ‘we
need C & R’, unless a sincere attempt is made to define what this
term means in reality.
References
Allen,
D., McDonald, L., Dunn, C., & Doyle, T. (1997).
Changing care staff
approaches
to the preventions and management of aggressive behavior in a residential
treatment unit for persons with mental
retardation and challenging behavior. Research In Developmental
Disabilities, 18, 101-112.
Allen,
D. (1998). Physical aggression in people with learning disabilities.
Allen, D. (2001). Physical Interventions:theory and research,
BILD: Avon.
Allison, S. (2002) Senior coach, British Jiu Jitsu association.
(Personal communication)
Barker,
P (2000). The Tidal Model: A Holistic Approach to Psychiatric and
Mental Health Nursing,(training manual).
Breakwell,
G. (1997). Facing Physical Violence. Routledge: London.
Cunningham,
J., McDonnell, A., Sturmey, P., & Easton, S. (2002). Asking people
with learning disabilities their views on restraint procedures. (Acceppted
for publication in Developmental Disabilities)
Gertz,
B. (1980) Training for Prevention of assaultive Behaviour in a Psychiatric
Setting. Hospital and Community Psychiatry, 31, 628-630.
Gilbert,
P. (1988) Exercising some Restraint. Social Work Today,
30, 16-18.
Gournay,
K. (2001) The Recognition, Prevention and Therapeutic Management of
Violence in Mental Health Care. (Draft document prepared for the UKCC)
Harris,
J. (1996) Physical restraint Procedures for Managing Challenging Behaviours
Presented by Mentally Retarded Adults and Children. Research in
Developmental Disabilities, 17, 2, 99-134.
Infantino,
J.A. & Musingo, S. (1985) Assaults and Injuries among staff with
and without training in aggression control techniques. Hospital
and Community Psychiatry, 36, 1312-1314.
Lefensky,
B., De Palma, B.T. & Lociercero, D. (1978) Management of Violent
Behaviours.
Perspectives in Psychiatric Care, 16, 212-217.
Lion,
J.R., Levenberg, L.B. & Strang, R.E. (1972) Restraining the Violent
Patient.
Journal of Psychiatric Nursing and Mental Health Services, 32,
497-498.
McDonnell,
A. & Sturmey, P. (1993a) Managing violent and aggressive behaviours
of people with learning difficulties. In Jones, R.S.P. & Eayrs,
C. (Eds) Challenging Behaviours and Mental Handicap: A Psychological
Perspective. Kidderminster: BILD.
McDonnell,
A. & Sturmey, P. (1993b) The acceptability of physical restrain
procedures for people with a learning difficulty. Behavioural and
Cognitive Psychotherapy, 21, 225-264.
McDonnell,
A. (1997) Training care staff to manage challenging behaviour: An
evaluation
of a three day course. British Journal of Developmental Disabilities,
43, 2, 85, 156-161.
McDonnell,
A.A., & Sturmey, P. The social validation of three physical restraint
procedures: a comparison of young people and professional groups.
Research in Developmental Disabilities, 21, 85-92.
McDonnell,
A.A., & Gallon, I. (2002a). Nurses understanding of the expression
control and restraint. (manuscript in preparation)
McDonnell,
A.A., & Gallon, I. (2002b). Developing an alternative to ‘C &
R’ in a psychiatric service: (manuscript in preparation).
Patterson,
B., Leadbetter, D & McComish, A. (1998). Restraint and sudden
death from asphyxia. Nursing Times, 94, 34-36.
Patterson,B.
& Leadbetter, D. (1999). Managing physical violence. In J Turnbull
& B Patterson (Eds) Aggression and Violence: Approaches to
Effective Management, MacMillan,: Basingstoke.
Royal
College of Psychiatrists (1995) Strategies for the Management of Disturbed
and Violent Patients in Psychiatric Units. Council Report CR41. London:
Royal College of Psychiatrists.
Stirling, C., & McHugh, A.(1997). Natural therapeutic
holding: a non aversive alternative to the use of control and restraint
in the management of violence for people with learning disabilities.
Journal of Advanced Nursing, 26, 304-311.
Tarbuck,
P. (1992). Use and abuse of control and restraint. Nursing Standard,
6, 30-32.
Whittington,
R. & Wykes, T. (1996) Aversive stimulation by staff and violence
by
psychiatric patients. British Journal of Clinical Psychology,
35, 11-20.
Wolf,
M.M. (1978). Social validity: The case for subjective measurement
or
how
applied behavior analysis if finding its heart. Journal of Applied
Behavior Analysis, 11 203-214.
