1. The princess and the frog!
Rosaline Kelly
Senior Professional Development Officer

2. Today’s aims
Improved understanding of what makes a practice restrictive;
Provide a framework for practice that embeds a rights based approach and puts the person at the centre of decision making processes.

3. Today’s objectives At the end today delegates will:
Understand what could potentially make a practice restrictive
Understand what a rights based approach means
Understand the importance of working within legal, ethical and professional accountability frameworks
Understand the “Three Steps to Positive Practice” process
Reflect on a number of case studies, identifying where the “Three Steps to Positive Practice” framework could be implemented.

4. Take home message – the princess and the frog

5. In my experience, there are very few decisions in nursing that weigh on us more heavily than whether or not to restrain someone.

6. Staff understanding
What is your current understanding of the term “restrictive intervention”?
Any practice which interferes with the liberty, and free choice of self-determination of any person
I am not familiar with the term restrictive intervention
Any intervention: physical, emotional, psychological, mechanical or pharmacological which restricts or prevents an individual or group of individuals from undertaking a specified range of activities that are time-limited; utilised as a last resort and which are intended to be withdrawn at the earliest opportunity
A measure taken to ensure a patient’s safety when they are at risk of endangering themselves, i.e. a patient at risk of falls who is confused may be sitting in a chair and their table is used as a device to stop them getting up independently
Any intervention which impacts on an individual’s freedom to make his/her own decisions or restricts his/her freedom of movement
I have no idea what it means
Any type of intervention (mechanical, physical, environmental, social) which is used to intentionally or unintentionally limit someone’s liberty
Using physical force to restrain an individual who may be endangering themselves or others

7. Definitions
“Restrictive practices are those that limit a person’s movement, day to day activity or function”
Three Steps to Positive Practice, 2017

8. Definitions
Put very simply restrictive practice means actions that stop a person from doing something that they want to do, or doing it in a way that they want to do it. Restrictive practices can also mean actions that make a person do something they do not want to do, or preventing a person from having something that they want

9. What makes a practice restrictive?
Some can be easily identified – locked doors, physically restraining a person
Others are more subtle – only allowing a person to watch television for a certain length of time
Psychological – attempting to exert control or force compliance by what is said, how it is said, and/or use of body language and non verbal communication
Care/treatment not intended to restrict but there are restrictive side effects – sleeping tablets
Control or abuse of a person’s finances
Restrictions necessary for one person could have a negative impact on others they live with
Restrictions because of restrictions placed on
others – safeguarding reasons

10. Is it wrong to use restrictive practices?
It is recognised that there are occasions when the use of restrictive practice is unavoidable in order to keep the person and/or others safe from harm.
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 circumstances, care must be safe, effective, person-centred and provided within legal, ethical and professional accountability structures.

12. Legislation Human Rights Act 1998
HPSS (Quality, Improvement & Regulation)(NI) Order 2003
Associated Regulations for regulated services
Mental Health (NI Order) 1986
Mental Capacity Act (NI) 2016

13. Standards & Guidance
The Quality Standards for Health and Social Care: Supporting Good Governance and Best Practice in the HPSS 2003
Professional registration codes of practice and behaviours
Reference Guide to Consent for Examination, Treatment or Care 2003
Organisational policy and procedure

14. Let’s talk about consent!
“It is a general legal and ethical principle that valid consent must be obtained before commencing an examination, starting treatment or physical investigation, or providing personal care….is a fundamental part of good practice. A health or social care professional who does not respect this principle may be liable both to legal action by the person and action by their regulatory body.”
“While there is no statute here setting out the general principles of consent, case law ("common law") has established that touching an individual without valid consent may constitute the civil or criminal offence of battery. “
Reference Guide to Consent for Examination, Treatment or Care, DHSSPS, 2003

15. Who can give consent?
Adults must provide consent on their own behalf. No other person such as a family member, friend or carer and no organisation can give or refuse consent to a health or social care service on behalf of an adult service user who lacks capacity to consent unless they have specific legal authority to do so.

16. What is “capacity”?
The ability to independently make decisions that affect any aspect of care/treatment
All adults are presumed to have capacity to make decisions independently unless proven otherwise
All reasonable help and support must be provided to assist in independent decision making
Lack of capacity cannot be based on age, disability, appearance, behaviour, medical condition (including intellectual disability, mental illness, dementia or scores on tests of cognitive function), beliefs, apparent inability to communicate, or the fact that the decision made seems unwise to the health and social care professional.

17. A rights based approach
Human Rights – Fundamental rights enshrined in the European Convention on Human Rights (ECHR) and incorporated into UK law – Human Rights Act 1998
Core principles and values that should shape practices and services – FREDA principles

18. Human rights
Article 2 – the right to life – protected by law, cannot be deprived of life save in the execution of a sentence of court… (Absolute right)
Death through negligence, severe malnutrition, decisions about life saving healthcare treatment, end of life/assisted suicide

19. Human rights
Article 3 – Prohibition of torture – absolute right not to be tortured or subjected to treatment or punishment that is inhumane or degrading
Measures used to control behaviours which in reality are shaming and humiliating, for example: not being allowed to have a meal, or being made to stand outside, as a means of managing a perceived “bad behaviour”

20. Human Rights
Article 5 – Right to liberty and security – right not to be deprived of liberty – “arrested or detained” except in limited cases specified in the article – eg – suspected or convicted of a crime – provided there is proper lawful provision – Mental Health (NI) Order 1986
Measures used to prevent behaviours perceived to be a risk to self or others, for example: improper or inappropriate admission/detention to psychiatric care; use of chairs with straps; use of “time out” or seclusion

21. Human Rights
Article 8 – Right to respect for private and family life – the right to respect for private and family life, home and correspondence (can be restricted only in specified circumstances)
Measures which prevent participation in family, social and recreational activities, for example: structural adaptions to accommodation which separate/isolate the person form others they live with; preventing or limiting contact with family or friends; use of restrictive clothing to limit perceived self-harm or inappropriate touch

22. Human Rights
Article 14 - Prohibition of discrimination – the right not to be treated differently because of their race, religion, sex, political views or any personal status, unless this can be justified objectively. Everyone must have equal access to Convention rights, whatever their status
Reducing access to services or opportunities available because of perception of risk or lack of resources to allow for suitable adaption and support, for example, a reduced school day; exclusion from social clubs

23. F R E D A Fairness Respect Equality Dignity Autonomy
FREDA Principles
F R E D A Fairness Respect Equality Dignity Autonomy

24. At a unit I worked in as a newly qualified nurse we had an open discussion of restraint criteria and practices with clients. The clients instigated this and the idea put forward by senior staff that any use of force was to maintain the safety of everyone in the unit including the person causing the risk had a surprisingly calming effect on the clients and appeared to reduce the number of incidents in the following days
The working group were very clear that the focus would be on the use of positive language, culture and values. We were very aware that many professionals struggle to understand what makes a practice restrictive and their legal, ethical and professional accountability in the use of a restrictive practice. We developed a simple definition to help professionals determine whether or not a practice or intervention is potentially restrictive.
This framework will assist any health and social care professional, no matter where they work, to ensure that the best interests of those in our care are at the centre of what we do, provide support and reassurance that any intervention used has been considered, planned and implemented legally and ethically.

25. Good Medical Practice. The Code: Professional
Good Medical Practice The Code: Professional standards of practice and behaviour for nurses and midwives

26. Standards of Conduct and Practice for Social Care Workers 2015
1. …you must protect the rights and
promote the interests and wellbeing
of service users and carers
3. …you must promote the autonomy of service users while safeguarding them as far as possible from danger or harm
4. …you must respect the rights of service users while seeking to ensure that their behaviour does not harm themselves or other people
6. …you must be accountable for the quality of your work and take responsibility for maintaining and improving your knowledge and skills

27. Standards of Conduct and Practice for Social Workers 2015
Standards of Practice…
2. Maintain an up-to-date knowledge and
evidence base for social work.
6. Assess needs, circumstances, rights, strengths and risks in partnership with those involved and respond appropriately.
7. Use social work interventions to manage risk and improve outcomes for service users.
8. Develop yourself and others.

28. Three Steps to Positive Practice

29. Step 1 - Consider and plan
consider if the planned intervention is a restrictive practice using the definition
consider other less restrictive measures
consider if the planned intervention is therapeutic in its intention

30. Step 2 – Implement the safeguards
use a rights based approach within professional accountability and legal frameworks to ensure that any restrictive practice is used only when deemed to be in the person’s best interests

31. Step 3 – Review and reflect
ensure that a regular and timely review of the use of a restrictive practice is built into a therapeutic plan to meet the person’s needs
this must include a plan to reduce or remove the restrictive practice as soon as is possible
ensure appropriate use of professional reflection support systems that consider the impact of the use of restrictive practices

32. SCENARIOS

33. Three Steps to Positive Practice
Framework designed to encourage careful consideration and reflection on the use of restrictive practice, before it is implemented and throughout the entire timeline when the practice may in use.
The process is applicable at the points of assessment, implementation, evaluation and review
It is also applicable in situations where the use of restrictive practices has been in place for some time, or are associated with a particular environment

34. Three Steps to Positive Practice
Three steps to positive practice embraces a new way of thinking, the creation of a new culture which will support staff to act differently, with an emphasis on a proactive, evidence based and rights based approach to practice
I recently worked with a 17 year old health care apprentice who had been taught positive behaviour support at college; her approach and attitude prevented and defused a number of potentially serious events with severely demented residents when the restrictive, restraining, medicating attitudes of more experienced staff were inflaming the situation

35. Three Steps to Positive Practice
Three steps to positive practice is intended to assist staff to ensure that the decisions they make and the actions they take are consistent with legal, ethical and professional accountability frameworks, every time a decision is made or an action is taken

36. Take home message – the princess and the frog

37. References
Three Steps to Positive Practice: a rights based approach when considering and reviewing the use of restrictive interventions
Three Steps to Positive Practice – video
Principles of Consent: guidance for nursing staff
The NMC Code: Professional standards of practice and behaviour for nurses and midwives
Reference Guide to Consent for Examination, Treatment or Care
Regulatory regulations and standards:
Standards of Conduct and Practice for Social Care Workers

38. https://youtu.be/vqWvP8bljg4