Care without responsibility ?

The very expression ‘Control and Restraint, can produce a wide range of responses from nurses working in mental health settings. My own feelings have changed over the years. Initially, I was grateful to receive effective training that would enable dangerous and difficult situations to be managed safely. However, I started to develop doubts about the appropriateness of ‘C & R’ when I became an instructor.

In 1992 I began to teach physical procedures including both ‘breakaway’ and restraint techniques to staff in my own service. Even though I was fairly closely supervised as an instructor, I began to become increasingly worried that some of the people I was teaching had the potential to abuse such methods. This raised even further questions about what people actually remembered and used after training. I also was concerned that there appeared to be very few people in the nursing profession who were willing to openly discuss their concerns about ‘C & R’. I began to look for viable alternatives to such training. Today I believe that a radical review of such training is needed. In the remainder of this article I will attempt to address 9 major concerns about such training, and offer some thoughts on future developments in this area.

Over the Top - This is my main criticism. For the majority of incidents three man teams are not needed. I certainly think it is inappropriate for use with older people. It is also inappropriate for those whose violence is not sophisticated or focused. Some staff seem to like the "drill".

Based on pain - The use of pain to control behaviour can vary from place to place. However, the use of pain wrist locks common place. John Hopton writing in Open Mind, the monthly journal from MIND wrote "Although it can hurt if the wrist locks ave applied in a heavy handed way, staff are taught to relax the lock slightly if they are causing pain to the person being restrained. when applied expertly and sensitively the experience of being restrained is one of being held firmly but gently". However, many people may find it difficult to apply a lock sensitively or in an expert manner when their own levels of adrenaline are very high.

Open to abuse - The infliction of pain is not consistent with the delivery of a quality service. Like it or not, there is the possibility that the person applying a wrist lock may have a grudge or may be angry. Painful technique should be excluded to safeguard against improper use.

Retention of Skills - We noticed at our hospital that many people who went on training courses quickly forgot what they had been taught. It seemed that there were far too many martial arts techniques, they were far too complicated and people had difficulty demonstrating the techniques shortly after attendance. Even worse, some people demonstrated variations which were either dangerous or ineffective

Content of Training - Different training establishments teach different variations of control and restraint. This can be very confusing. There is no regulation or approval of which techniques should be used (see below). B. Home Office Approval - Home Office approval for control and restraint does not exist outside the Prison Service. The Home Office does not approve training for the NHS. Some services still think the courses are Home Office approved.

Staff' Injuries - A number of staff have received injuries whilst training in C & R techniques - i.e. badly bruised ribs. Discussion with colleagues from around the Trent region leads me to believe this is not uncommon.

Litigation - Restraint should be appropriate for the situation. With reference to my first point, if restraint is over the top, then it may be considered by the

Deaths - A number of deaths have occurred following restraint eg. David Falconer in Devon. An article in Open Mind - January 1998, by Raj Persaud pr~cis a paper which appeared in the British Medical Journal entitled "Acute Excited States and Sudden Death". The following is an extract - " In the tragic situation where a patient in a psychiatric hospital dies suddenly and unexpectedly, large doses of medication are often blamed. However, it may be that other factors should also be taken into account. A series of studies has shown that even stress induced by everyday activities such as driving in heavy traffic and public speaking provokes heart rhythm disturbances ... Research into sudden death has found being restrained to be a prominent factor and common fhenze. Physical restraint, from a psychological standpoint, cuts off the two major ways of coping with aversive situations fight ovfli~lzt. While in Most cases restraint does not result in sudden death, however, when combined with induced or already existing cardiac disturbance, and acute emotional stress, all thesefactors raise the probability of sudden death. In-patient units, where the added danger of high doses of psychotropic medication may be included in this hazardous equation, need therefore to take particular care - to prevent such situations where the combination occursfrom developing in the firplace,".

Note from Dave Sheppard The Mental Health Act Code of Practice (Revised ~999) states: Staff in NHS hosl?itnls andprivate mental nursing homes who are ordinarily likely toJind thenlsc~lves in situations where training in the management ofactual orpotential aggression might De necessary should attend an appropriate course taught by a qualified tminev. T/ze trainer should have completed art appropriate course ofprepamtion designedfor health care settings andpreferably validated by one of the health care bodies (English National Board or Royal College of Nursing Institute).

Mental Health Act Code of Practice, para. 19.9 - revised 1999