Holding & restraining


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Evesham 4th Jan 2012

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Holding & restraining

  1. 1. Restrictive physicalintervention andtherapeutic holding forchildren and young peopleGuidance for nursing staff
  2. 2. This Royal College of Nursing guidance sets out children’s and young people’s rightsconcerning physical restraint and the restriction of liberty in health care settings withina legal, moral and ethical framework.The Restraining, holding still and containing young children guidance was firstpublished in 1999, and was updated in 2003, following consultation with RCNmembers. This new 2010 guidance replaces previously published information.AcknowledgmentsThe Royal College of Nursing would like to thank Sally Ramsay for reviewing andupdating this guidance.© 2010 Royal College of Nursing. All rights reserved. Other than as permitted by law no part of this publicationmay be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic,mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licencepermitting restricted copying issued by the Copyright Licensing Agency, Saffron House, 6-10 Kirby Street,London EC1N 8TS. This publication may not be lent, resold, hired out or otherwise disposed of by ways of tradein any form of binding or cover other than that in which it is published, without the prior consent of thePublishers.
  3. 3. ROYAL COLLEGE OF NURSINGRestrictive physicalintervention and therapeuticholding for children andyoung peopleGuidance for nursing staffContents1. Introduction Page 12. Restrictive physical intervention and therapeutic holding Page 13. Definitions Page 24. The principles of good practice Page 35. Training Page 56. References and further resources Page 5
  4. 4. RESTRICTIVE PHYSICAL INTERVENTION AND THERAPEUTIC HOLDING1 2Introduction Restrictive physicalThis guidance is not intended to be a comprehensivemanual covering all situations and methods; instead it intervention andis a set of principles and key references which willhelp nurses to develop policies, practices and therapeutic holdingeducational programmes in their workplace, inconjunction with other members of themultidisciplinary team. The governing body of healthcare organisations should approve the implementationof these policies; including ensuring staff receivenecessary training in order to practice the necessarytechniques competently. Nurses’ duty of care Registered nurses are bound by a ‘duty of care’ (Nursing and Midwifery Council (2008a)) and are accountable for promoting and protecting the rights and best interests of their patients. Where the use of restraint, holding still and containing children and young people is concerned, nurses must consider the rights of the child and the legal framework surrounding children’s rights, including the Human Rights Act (Human Rights Act 1998) and the European Conventions on the Rights of the Child, Consent and Capacity Assessment (UN Convention on the Rights of the Child (1989)). Return to contents 4 1
  5. 5. ROYAL COLLEGE OF NURSING3Definitions De-escalation techniques These are techniques to reduce the level and intensity of a difficult situation. De-escalation means making a risk assessment of the situation and using both verbal and non-verbal communication skills in combinationRestrictive physical to reduce problems.interventionThis term is increasingly replacing the term ‘restraint’ Therapeutic holdingas it encompasses a range of approaches (Hart,Howell, 2004). It is described as direct physical This means immobilisation, which may be bycontact between persons where reasonable force is splinting, or by using limited force. It may be apositively applied against resistance to either restrict method of helping children, with their permission, tomovement or mobility or to disengage from harmful manage a painful procedure quickly or effectively.behaviour displayed by an individual (Welsh Therapeutic holding is distinguished from restrictiveAssembly Government, 2005). It should only be used physical intervention by the degree of force requiredto prevent serious harm. and the intention.In a report on restrictive physical interventions in Alternative terms for therapeutic holding includechildren’s homes Hart (2008) described it as “any ‘supportive holding’ (Jeffery, 2008) and ‘clinicalmethod that restricts the movement of an individual holding’ (Lambrenos, McArthur 2003).by physical means, including mechanical means,holding and physical restraint.” Practitioners should be aware that therapeutic holding if applied inappropriately and without the child’sAll UK countries issue guidance on restrictive physical consent or assent can result in the child/young personinterventions relevant to school, children’s homes and feeling out of control, anxious and distressed.detention centres. The British Institute of Learning (Labrenos, McArthur, 2003).Disabilities publishes a code of practice for the use ofphysical interventions (BILD, 2006).The physical restraint or barriers which prevent thechild leaving, harming themselves, or causing seriousdamage to property (previously known as‘containing’) are also included in the term restrictivephysical intervention. All restriction of liberty inhealth care setting is governed by the 1991 Children(Secure Accommodation) Regulations, the ChildrenAct 1989 (Department of Health (1997)), the Children(Northern Ireland) Order (Department of Health(1995)) and the Children (Scotland) Act (ScottishOffice (1998)). Return to contents 2
  6. 6. RESTRICTIVE PHYSICAL INTERVENTION AND THERAPEUTIC HOLDING4The principles of Therapeutic holdinggood practice Therapeutic holding for a particular clinical procedure also requires nurses to: ll give careful consideration of whether theGeneral principles procedure is really necessary, and whether urgency in an emergency situation prohibits theGood decision-making about restrictive physical exploration of alternativesinterventions and therapeutic holding requires that in ll anticipate and prevent the need for holding, byall settings where children and young people receive giving the child information, encouragement,care and treatment, there is: distraction and, if necessary, using sedation (Scottish Intercollegiate Guideline Networkll an ethos of caring and respect for the child’s (2002)) rights, where the use of restrictive physical ll in all but the very youngest children, obtain the interventions or therapeutic holding without the child’s consent (Department of Health (2001)) or child/young person’s consent are used as a last assent (expressed agreement) and for any resort and are not the first line of intervention situation which is not a real emergency seek thell a consideration of the legal implications of using parent/carer’s consent, or the consent of an restrictive physical interventions. Where independent advocate necessary, application should be made through ll make an agreement beforehand with parents/ the Family Courts (or equivalent in Scotland and guardians and the child about what methods will Northern Ireland) for a specific issue order be used, when they will be used and for how long. outlining clearly the appropriate restraint This agreement should be clearly documented in techniques to be used the plan of care and any event fully documentedll an openness about who decides what is in the ll ensure parental presence and involvement - if child’s best interest – where possible, these they wish to be present and involved. Parents/ decisions should be made with the full agreement guardians should not be made to feel guilty if they and involvement of their parent or guardian do not wish to be present during procedures.ll a clear mechanism for staff to be heard if they Nurses should explain parents’ roles in supporting disagree with a decision their child, and provide support for them duringll a policy in place which is relevant to the client/ and after the procedure patient group and the particular setting and ll make skilled use of minimum pressure and other which sets out when restrictive physical age-appropriate techniques, such as wrapping and interventions or therapeutic holding may be splinting, explaining and preparing the child/ necessary and how it may be done parents beforehand as to what will happenll a sufficient number of staff available who are ll comfort the child or young person where it hasn’t trained and confident in safe and appropriate been possible to obtain their consent, and explain techniques and in alternatives to restrictive clearly to them why immobilisation is necessary. physical interventions and therapeutic holding of children and young peoplell a record of events. This should include why the Note intervention was necessary, who held the child, where the intervention took place, the method Effective preparation, the use of local anaesthetic, used, the length of time and any techniques sedation (Scottish Intercollegiate Guideline Network needed to reduce the future need for restrictive (2002)) and analgesia, together with distraction physical interventions of therapeutic holding techniques, successfully reduces the need for undue (Jeffrey, 2008). force in the use of proactive immobilisation - for example, when holding a child’s arm from which Return to contents 6 3
  7. 7. ROYAL COLLEGE OF NURSINGblood is to be taken or when administering an Noteinjection, in order to prevent withdrawal andsubsequent unnecessary pain to the child. However, The restraint of children within health care settingstherapeutic holding without the child’s consent or may be required to prevent significant and greaterassent may need to be undertaken against the child’s harm to the child themselves, practitioners or others.wishes in order to perform an emergency or urgent For example in situations where the use of de-intervention in a safe and controlled manner - for escalation techniques have been unsuccessful forexample, in order to perform a lumbar puncture. children/young people under the influence of drugs or alcohol and who are violent and aggressive. If restrictive physical interventions are required the degree of force should be confined to that necessary toRestrictive physical hold the child or young person whilst minimisingintervention and therapeutic injury to all involved.holding requires:ll policies which relate to the organisation’s philosophy on the provision of child-friendly health care. Policies should include when and how restrictive physical interventions and therapeutic holding should be used, who to notify, time limits and the reporting and recording of incidents through critical incident reporting mechanismsll anticipation and prevention of the need for restrictive physical interventions and therapeutic holding including provision of training sessions to clearly identify individual roles and responsibilitiesll that when it is likely to be necessary, there is agreement beforehand with parents and the child about what methods will be used and in what circumstances. This agreement should be clearly documented in the plan of carell that consideration is made to the legal implications of restraint. Where necessary, application should be made through the family courts (or equivalent in Scotland and Northern Ireland) for a specific issue order outlining clearly the appropriate restraint techniques to be usedll that physical restraint is never used in a way that might be considered indecent, or that could arouse any sexual feelings or expectationsll that debriefing of the child and, where appropriate, of parents and staff, takes place as soon after the incident as possiblell effective audit of the circumstances and use of restrictive physical interventions and therapeutic holding. Return to contents 4
  8. 8. RESTRICTIVE PHYSICAL INTERVENTION AND THERAPEUTIC HOLDING5 6Training References and further resourcesMany nurses do not receive specific training intechniques of restrictive physical intervention andtherapeutic holding and as a result lack confidence in British Institute of Learning Disabilities (2002)using these techniques. Greater emphasis needs to be Factsheet on physical interventions.placed on enabling nurses to acquire knowledge and www.bild.org.uk/pdfs/05faqs/pi.pdfskills through the provision of locally based trainingprogrammes. It is recommended that organisations Charles-Edwards I (2003) Power and control overundertake an organisation-wide risk assessment to children and young people. Paediatric Nursing 15(6)assess particular risks in each clinical area and thus pp37-43identify staff training needs. Department of Health (1993) Guidance on PermissibleTraining provision should be differentiated between Forms of Control in Children’s Residential Care,restrictive physical interventions and therapeutic London: DHholding for clinical procedures, and targeted atrelevant groups of nurses. For example, nurses Human Rights Act 1998 www.hmso.gov.uk/acts.htmworking in areas such as emergency care departments,walk-in centres and GP practices should receive European Conventions on the Rights of the Child,training in using restrictive physical interventions as Consent and Capacity cited in UN Convention on thewell as therapeutic holding for clinical procedures; Rights of the Child (1989) (20.Xi. 1989; TS 44; Cmnurses working with children and young people in all 1976)other clinical areas should receive, as a minimum,training in therapeutic holding for clinical procedures Department of Health (2002) Guidance for Restrictiveand de-escalation techniques. Physical Interventions: How to provide safe services for people with learning disabilities and spectrum disorder, London: DHHighlighting the need fortraining Department of Health (2004) National Service Framework for children, young people and maternityPractitioners who want to highlight the need for services, London: DH.policies and training provision in their organisationmay find it helpful to forward a copy of this guidance Department of Health (1997) The Control of Childrento risk managers and named executive directors (or in the Public Care: Interpretation of the Children Actequivalent) for their place of employment. If 1989. London: DHemployers do not provide proper training,practitioners may feel compromised in situations Department of Health (1995) The Children (Northernwhere they have found it necessary to use restrictive Ireland) Order, London: DHphysical interventions. Folkes K (2005) Is restraint a form of abuse?,RCN members can seek specific advice about these Paediatric Nursing, 17(6) pp41-44issues by contacting RCN Direct on 0345 772 6100 ortheir local RCN office (contact numbers can be found Department of Health, Social Services and Publicin the RCN members’ handbook). Safety, Northern Ireland (2003) Seeking consent: working with children. www.dhsspsni.gov.uk/The publication Raising concerns, raising standards (RCN, consent-guidepart2.pdf2009) will also be of help. Publication code: 003 532 Return to contents 8 5
  9. 9. ROYAL COLLEGE OF NURSINGHart D and Howell S (2004) Report on the use of Royal College of Nursing (2008b) Dignity. At the heartphysical interventions across children’s services, of everything we do, www.rcn.org.uk/publicationsLondon: NCB Royal College of Nursing (2009) Raising concerns,Jeffery K (2008) Supportive holding of children during Raising standards, London: RCNtherapeutic interventions in Kelsey, J. and McEwing G. Scottish Intercollegiate Guideline Network (2002) Safe(eds) Clinical skills in child health practice. London: Sedation of Children undergoing Diagnostic andChurchill Livingstone Elsevier Therapeutic procedures, Edinburgh: SIGN. www.show.scot.nhs.ukLambrenos K McArthur K (2003) Introducing aclinical holding policy, Paediatric Nursing, 15(4) Scottish Government (2009) Better health, Better Care.pp30-33 Hospital services for young people in Scotland, www.scotland.gov.uk/publicationsNursing and Midwifery Council (2007) Record keepingadvice sheet, www.nmc-uk.org Scottish Office (1998) Children (Scotland) Act in The Scottish Office NHS Policies for Children – 1974-1998:Nursing and Midwifery Council (2008a) Code, An overview, Edinburgh: The Stationery Officestandards of conduct, performance and ethics for nursesand midwives, London: NMC Valler-Jones T. Shinnick A. (2000) Holding children for invasive procedures: preparing student nurses,Nursing and Midwifery Council (2008b) Consent, Paediatric Nursing 17(5) 20-22London: NMC. Welsh Assembly Government (2005) National ServiceNursing and Midwifery Council (2008c) Advice for Framework for Children, Young People and Maternitynurses working with children and young people, Services in Wales,London: NMC www.wales.nhs.uk/sites/home.cfm?OrgID=441Paley S, Brooke J (eds) (2006) Good practice in Welsh Assembly Government (2005) Framework forphysical interventions: a guide for staff and managers, restrictive physical intervention: policy and practice,www.bild.org.uk www.wales.gov.ukPearch J (2005) Restraining children for clinicalprocedures, Paediatric Nursing 17(9) pp36-38Robinson S, Collier J, (1997) Holding Children Still forProcedures, Paediatric Nursing 9, 4, pp12-14Royal College of Nursing (2003) Caring for youngpeople: guidance for nursing staff, London: RCNRoyal College of Nursing (2006) Violence. Theshort-term management of disturbed/violent behaviourin in-patient psychiatric settings and emergencydepartment, Clinical practice guideline, London: RCNRoyal College of Nursing (2008a) Work-relatedviolence. An RCN tool to manage risk and promotesafer working practices in health care, London: RCN Return to contents 6
  10. 10. The RCN represents nurses and nursing,promotes excellence in practice and shapeshealth policiesMarch 2010RCN Onlinewww.rcn.org.ukRCN Directwww.rcn.org.uk/direct0345 772 6100Published by the Royal College of Nursing20 Cavendish SquareLondonW1G 0RN020 7409 3333Publication code 003 573ISBN 978-1-906633-36-3