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But wait!

Do you understand what makes a practice restrictive? Many health and social care staff don’t. Some staff have a very clear understanding of what potentially makes a practice restrictive; others have little or no understanding. And in many cases, staff don’t realise that they are impacting on people’s rights and/or potentially breaking the law.

Restrictive practices can be difficult to define and even more impossible to list, simply because they are not always very obvious or because staff might justify the practice in the context of keeping someone “safe”.

Here are some examples of restrictive practices:

• physical restraint
• locking doors to keep a person confined to a building or a certain area
• use of equipment like bed rails, lap straps, alarm mats
• limiting the time a person can watch television every day
• prescription of certain medications not designed to restrict, but which have restrictive side effects, like sleeping tablets
• no choice on time to get up or go to bed
• psychological - attempting to exert control or force compliance by what is said or how it is said, and/or the use of body language and nonverbal methods of communication.

• in some cases the person could be restricted because of restrictions placed on others, maybe where the person’s family is not allowed to have contact with them for safeguarding reasons
• where a group of individuals live in the one place, restrictions necessary for one person could impact negatively on their fellow tenants.
• control and/or abuse of a person’s financial matters (often unrecognised as a restrictive practice).

In the past we did the best with what we knew; now we know better. The explicitly requires nurses to “always practice in line with best available evidence”. Likewise standards require social care workers to “promote the autonomy of service users while safeguarding them as far as possible from danger or harm”.

We know that behaviours that challenge staff and carers are a form of communication or a distressed reaction to something the person is experiencing. We know that many of the strategies we used in the past, or might be currently using, are punitive rather than therapeutic. So we need to change what we are doing to make sure that all of our interventions are evidence based and truly serve the person’s best interests.

We also know that there are occasions when the use of restrictive practice is unavoidable in order to keep the person and/or others safe from harm. Restrictive practices are not inherently wrong, harmful or illegal. They can help to keep people safe and create opportunities for them to learn new skills.

When restrictive practices are as part of a comprehensive therapeutic plan that is outcomes focussed and fully embraces a person’s rights, and when there is no other way to keep people safe, then they can and often should be used. In these situations, staff must ensure that the care, treatment and support they provide is safe, effective, person-centred and provided within legal, ethical and professional accountability structures. Three steps to positive practice is a framework designed to help staff to think about culture and practices and guide professional, ethical and legal decision making when considering the use of potentially restrictive practices. Three steps to positive practice is the framework that all health and social care staff are required to follow if using any form of restrictive practice as set out in the.

A multi-disciplinary team, led by RCN NI comprising nursing, psychiatry, social work and occupational therapy worked together to develop this simple three step cyclical framework.

CONSIDER & PLAN

IMPLEMENT THE SAFEGUARDS

REVIEW & REFLECT

The framework emphasises the importance of the focus on human rights and the core principles which must shape practices and services and put the person at the centre of the delivery of health and social care. 

This is not a framework owned solely by those working in mental health or learning disability services. Those who may be subject to restrictive practices are our most vulnerable service users; they receive services throughout the health and social care systems. The multi-disciplinary nature of the group emphasises the fact that this framework is not owned by any one profession, any specialty within the professions, or any specific care or treatment setting.

Three Steps to Positive Practice empowers all staff to ask questions if they are not satisfied that a proposed intervention will be in the person’s best interests and to ensure that adjustments are made. It will provide staff with the support and reassurance that any intervention used has been considered, planned and implemented legally and ethically.

This means YOU! If YOU think a person in your care is unnecessarily or disproportionately restricted, YOU can use this framework to challenge the practice. If YOU are involved in planning or implementing a restrictive practice, this framework should be used before the practice is implemented, and the throughout the entire time the practice is in use.

YOU can live out the standards of behaviour and practice expected of a nurse, and YOU can provide authentic, holistic, person-centred care. Isn’t that the dream?

Rosaline Kelly

Senior Nurse Professional Practice