care, health and development Child: Original Article bs_bs_banner
doi:10.1111/cch.12193
The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential services for children and young people R. Deveau* and S. Leitch† *Tizard Centre, University of Kent, Kent, UK †Leitch Consultancy, Appin, Argyll, UK Accepted for publication 21 August 2014
Abstract
Keywords challenging behaviour, child care, reflective practice, residential and respite care Correspondence: Roy Deveau, Tizard Centre, University of Kent, Giles Lane, Canterbury, Kent CT2 7LZ, UK E-mail: [email protected]
Aim The aim was to examine the impact of post restraint reduction meetings upon the frequency and restrictiveness of restraint use in English children’s residential services. Background Attention has been drawn to the misuse, overuse and safety of some techniques used to physically restrain children in residential services. Successful interventions to reduce restraints have been reported, mostly from the USA. Results Demonstrate a significant overall reduction in both, frequency and restrictiveness of restraints; the greatest percentage decrease in the most restrictive floor restraints. Whilst five services reduced both frequency and restrictiveness, five services showed some increases in frequency and/or restrictiveness of restraints employed. Conclusions Restraint reduction is most effectively reduced through employing multiple strategies and that post restraint reduction meetings maybe one useful component. Organisations seeking to promote restraint reduction meetings need to allocate sufficient priority and resources to support these.
Introduction Public and professional attention has been drawn to suggested misuse, overuse and safety of some techniques used to physically restrain children in residential services. Government guidance in England states that ‘reasonable’ restraint use should only be as a ‘last resort’ to prevent children harming themselves, harming others or damaging property (Department of Health 1991). Subsequent guidance also recommends that staff working in children’s services should be trained in approved restraint techniques and organisations monitor the use of such techniques (Department of Health and Department for Education and Skills 2002). This paper uses the term restrictive physical interventions (RPI) and restraint interchangeably. One commonly used definition of RPI states:
© 2014 John Wiley & Sons Ltd
Restrictive physical intervention refers to the actions by which one person restricts the movement of another. (Harris 1996, p. 20). Children living in residential settings, away from their families, do so for a wide variety of reasons, e.g. having offended or a wide variety of social/emotional needs, such as intellectual disabilities or mental health problems that families cannot meet. Widespread use of restraint has been reported for children in some youth justice services (e.g. HM Chief Inspector of Prisons 2012). In other residential settings, e.g. care homes and hospitals, evidence suggests that around half of children admitted are subject to physical restraints, including children with learning disabilities and challenging behaviour (Emerson 2002; McGill et al. 2009) in general care homes (Lindsay & Hosie
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2000) and in residential schools (Pilling et al. 2007; McGill et al. 2009). For example, of 156 pupils exhibiting significant challenging behaviours, in nine 52-week residential schools, 69% had experienced RPI at least annually with 18% experiencing this daily and a further 19% weekly (Pilling et al. 2007). Restraining children may lead to physical and mental harm for children subject to such practices. For example, of 142 restraint-related deaths in the USA (Weiss et al. 1998) 37 were children (Nunno et al. 2006). Some restraint positions; prone floor restraint, wraps and basket holds carry risk of positional asphyxia (O’Halloran & Frank 2000; Nunno et al. 2006). Children may be particularly vulnerable to emotional harm or traumatization if forcibly held by adults while in care, especially children who have experienced previous abusive trauma (Mohr et al. 2003). Restraint is distressing to witness and many children subject to physical restraint describe feelings of sadness, guilt, anger, claustrophobia and panic. Negative emotions are felt particularly, if staff are seen as using unnecessary force and/or causing pain (Petti et al. 2001; Morgan 2004; Steckley & Kendrick 2007). However, some children report positive impacts from being restrained e.g. made them feel safe and cared for (Steckley & Kendrick 2007). The problems associated with restraint use in children’s residential services led to interventions designed to achieve restraint reduction (e.g. Bullard et al. 2003; LeBel et al. 2004; Allen 2011). The Child Welfare League of America (Bullard et al. 2003) reported reductions of mechanical/physical restraints or seclusion within five children’s services, including a school, and a psychiatric hospital, using leadership and organizational change, data monitoring, staff development and policy/procedural change. Additional positive outcomes may be linked with reduction of restraint, e.g. lower staff sickness and injuries (LeBel & Goldstein 2005). However, organizational supports for staff and children to develop alternatives to RPI are required (Liberman 2011). Achieving restraint reduction probably requires multiple strategies including: leadership and organizational change, monitoring use of RPI to inform practice, workforce development, extending consumer roles/ participation, staff debriefing and external review (Colton 2004; Huckshorn 2004; Allen 2011). Individual debriefing of staff following their involvement in restraint use in recommended in UK guidance. The restraint reduction meeting (RRM) is a variant of de-briefing, a team meeting of staff, led by a manager or senior practitioner, to consider alternatives to restraint following its use. Reduction in the use of seclusion and restraint has been reported in adult services following the introduction of RRM (Donat 2003). However, no reports of RRM in children’s services was found.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
Method A longitudinal pre–post-intervention design examined the impact of an intervention RRM upon the frequency and restrictiveness of RPI in children’s services in England. Ethical approval was gained from the University of Kent and the Association of Directors of (local authority) Children’s Services.
Settings Participating services/organisations were recruited through an advertisement in the National Centre for Excellence in Residential Childcare website. Of 30 potential services that expressed an interest 10 participated. A variety of reasons for nonparticipation included: staff changes, service closed, changes in client group or difficulty in assuring data collection. The researcher, second author, visited all services to explain the study and assess suitability to participate. The main contact in services was the service/home manager or behaviour consultant. Inclusion criteria for participation were: the service was residential, using some RPI on a regular basis, did not currently conduct RPI reduction meetings and the young people, care staff and parents agreed to take part in the study (Table 1). Data were collected for different periods because of the diversity of service configuration, e.g. service P a residential school was closed at weekends. Pre-intervention data were collected on the use of RPI for 3 months from eight services, for 5 months from service A because it was used to pilot the research procedure and for 7 weeks for service P where a long school holiday limited data collection. Service differences also affected the duration of data collection following commencement of RRM. Postintervention data were collected from six services for 6 months, for 4 months from two services (A and M) and for 5 months for service C; 9 weeks of post-intervention data were collected from service P. Frequency data reported are mean per month/week. To ensure consistent data for the two training packages, six categories were developed to record the level of restrictiveness of restraint employed see Table 2.
The intervention Following baseline data collection the researcher revisited each service and conducted a standardized workshop to introduce the concept and conduct of the RRM. The 2-h workshop covered, purpose of and criteria for the RRM, possible attendees, outcomes and actions of the meeting and recording of the meeting. Opportunity to practice completion of the RRM form, ask questions and discuss potential problems was provided. Services were expected have a RRM within 72 h of every
Voluntary One Local Authority Children’s Social Services Department
One large voluntary organisation
Voluntary
A C D E
I L M N O
P
Residential service of a term time residential school
Children’s home Children’s home Children’s home Children’s home Children’s home
Residential short break (10–18) Children’s home residential full-time Children’s home residential full-time Children’s home residential full-time
Type of service (age group – years)
Behaviourally & Emotionally disturbed
Looked After Children – behaviourally and emotionally disturbed (BESD)
Learning Disability Looked After Children – generic
Characteristics of service users
10
5 2 2 4 6
5 5 5 5
No. of places
10
9 8 8 8 10
7 11 11 11
No. of staff (FTE)
Proact-Scipr-UK
Proact-Scipr-UK
Proact-Scipr-UK GSA General Services
Behaviour support training package
Touch support. Front deflection
Proact-Scipr-UK
2-person
Friendly come along (1 staff)
1-person escort. Front arm catch. Front approach prevention
Friendly come along (2 staff) Standing figure of four
2-person escort
One or two staff on either or both sides of a child holding the child’s arms sometimes used to walk the child to another destination
1-person
Floor hold. Pick up from floor
Supine (face up) or prone (face down) child is held on the floor with staff holding legs and arms. Usually 3 or 4 staff involved Supine Wraps: one staff is positioned behind the child either seated or standing holding the child’s arms across their chest Hug wrap
Seated figure of four The wrap
Floor holds
Seated holds and wraps
Other planned or not
Seated holds: one or two staff sit beside/or either side of a child usually holding them by having their arms around the back of the child holding the child’s arms on the opposite sides. Sometimes staff may place their legs over the child to prevent the child from moving.
General Services Association (GSA)
Minimum
Category of interventions (1–6) Description of intervention
Table 2. Physical intervention categories mapped for different training packages
All services provided training for staff in behavioural management, including physical interventions. Training was provided by either General Services Association (GSA) ([email protected]) or Proact-Scipr-UK (http://www.proact-scipr-uk.com). FTE, full-time staff equivalents.
Provider organisation
Service code
Table 1. Details of participating services
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© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
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RPI category
Pre-intervention
Post-intervention
Mean change
1 (minimal holding) 2 (one-person escort) 3 (two-person escort) 4 (seated holds) 5 (floor holds) 6 (Other) Totals Overall means (SD)
8.8 21.6 17.5 20.6 16.9 4.5 89.9 14.9 (6.8)
2.1 13.4 14.7 15.2 8.6 7.3 61.3 10.2 (5.0)
−6.7 −8.2 −2.8 −5.4 −8.3 +2.8 −28.6
RPI employed. Sources of advice and support for the manager on positive behaviour support or additional professional expertise were also identified during this workshop if they were needed or requested. Separate information was distributed for the young people, staff and professionals involved with the children and parents/carers. Key workers were supported to explain the study to children and the study was discussed in staff and in children’s meetings. An information guide to RRM was provided for managers. Following workshops, the researcher provided ongoing support through phone contact, email and personal visits; no visits were undertaken to services (C, D and E) one visit to services (I, L, M, N and O) two visits service A and three visits to service P. The service manager, senior manager or behavioural specialist collected and submitted data.
Measures The following data were collected from services, monthly or weekly (from service P) on separate incidents of RPI (incident forms): • Child code (each child was given a code by the service to ensure anonymity); • The type specified was the name given to the type of restraint by the organisation that had provided the training, e.g. basket hold, supine restraint, two person escort. The restrictiveness of physical intervention was grouped into categories by the researcher: 1 minimum force used, 2 one-person restraints, 3 two-person restraint, 4 seated holds, 5 wraps and floor restraints, and 0 other; • Length of time RPI was used. Incident forms also had room for a brief description of the event leading up to the incident. In cases where more than one RPI was involved in the same incident, often a progression directly from one to the other, these are recorded as two restraints, e.g. if a young person was escorted by two people
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
Table 3. Mean monthly frequencies in six restrictive physical interventions (RPI) categories for 10 services pre- and post-intervention
through the living room and then held sitting on the sofa this is recorded as a 3 and a 4. Completed incident forms were emailed or posted to the researcher monthly or weekly. Incident form data were only entered into the analysis if the child continued to receive support, newly admitted children or those who moved were excluded (see Table 4). Only 57 RRM forms were returned (see Discussion). The researcher was able, through follow-up with services, to conclude that post-incident meetings were usually held when RRM forms were not completed. To assess the coding reliability of restrictiveness of physical intervention (PI) employed, as described by services and subsequently categorized by the researcher, just over 10% of incident forms were coded blind by three other research students at the university department supervising the research. Overall agreement between the researcher and others was 95.3%. Any incident forms with unclear information were followed up by the researcher and on two occasions excluded from the study.
Results Overall results in Table 3 show reductions in use of all categories of PI except for the ‘Other unplanned or planned’ category. The greatest decrease is in the most restrictive floor restraints. The reduction in total RPI use over all categories was 31.6%. A paired samples t test on overall means was statistically significant [t = 2.759 (d.f. = 5) exact P = 0.04]. The use of restraint varied widely within participating services (see Table 4). The restrictiveness scale was calculated from the monthly PI categories by counting each category as a numerical item, e.g. a category 2 (one-person hold) was scored as two on the scale and a category 5 (floor hold) was scored as five on the restrictiveness scale. For example, two RPI, a oneperson hold and a floor restraint would be reported as 2 on the frequency totals and 7 in the restrictiveness totals. The ‘other’ RPI category was scored on the frequency measure but not scored on the restrictiveness scale. Services A, C, E and M demonstrated reduction in frequency and restrictiveness of RPI employed. Service L had a low use of
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Table 4. Frequency and restrictiveness of restraint employed in services, mean per month/week (Number of children subject to RPI) and number of incident forms returned/per service A C D E I L M N O P
(7) (3) (1) (4) (3) (1) (2) (2) (4) (8)
34 8 30 31 153 3 13 13 47 251
Frequency of all RPI employed total (mean per month)
RPI restrictiveness scale mean per month
Pre-intervention
Post-intervention
Pre-intervention
Post-intervention
39 (7.8) 11 (3.7) 11 (3.7) 26 (8.7) 68 (22.7) 3 (1.0) 18 (6.0) 4 (1.3) 30 (10.0) 168 (24)
12 (3.0) 0 (0.0) 28 (4.7) 22 (3.7) 151 (25.2) 2 (0.3) 6 (0.86) 12 (2.0) 60 (10.0) 177 (19.7)
15.4 15.3 13.3 27.6 72.7 1.0 9.7 3.0 21.3 72.4
6.0 0 16.0 12.3 58.7 0 1.6 5.8 24.7 80.0
Statistics for service P refer to weeks rather than months. RPI, restrictive physical interventions.
RPI at baseline and stopped using RPI. The remaining five services demonstrated little difference in RPI use: Service I demonstrated a small increase in frequency but reduced restrictiveness of RPI, services O and P showed no change or a small decrease in frequency but an increase in the restrictiveness of RPI, services N and D showed small increases in both frequency and restrictiveness of RPI.
Discussion Limitations The current study has significant limitations. First, limited data on intervention fidelity, RRM was not monitored so the content or consistency of these meetings is uncertain, e.g. in some instances of RPI use they may not have been held. Second, no assessment on the reliability of level of RPI recorded by staff on incident forms was possible, leading to potential data drift in recording by staff, aware of the research process and purpose. Third, confounding variables were not assessed, e.g. the training and support for frontline staff or the quality of leadership. Fourth, the intervention period was limited and may not reflect the potential of RRM/extended de-briefing. Lastly, applying these results more generally, from self-selected services, is not to be done uncritically. However, the variability in outcomes provides some ‘face validity’ to the results.
Implications The current study sought to examine the independent impact of RRM in reducing RPI within complex service environments. The limited overall significance and variability in results suggests that other factors were important. For example, leadership in services
that choose to participate and additional external review by the researcher (which varied in participating services) may have been influential. The use of multiple strategies in a wide variety of contexts, make valid conclusions about the effectiveness of particular components difficult (Allen 2011). The role of RRM in reducing restraint and their relationship to other possible interventions in multi-component approaches requires further research. The current study suggests that services and organisations are all different and that the model of RRM must be flexible to meet the needs of particular service settings. Finding time to organize and conduct RRM was a significant barrier. Some services conducted RRM as part of team meetings or during handovers. RRM may be especially difficult to manage during periods where there are high levels of incidents. The current study suggests the importance of organisations allocating resources and priority to these activities.
Key messages • Restraint is associated with significant problems, including death and continues to be used in some services for children with significant frequency. • Reduction in the frequency and/or restrictiveness of restraint employed in services is an important policy goal and is probably best achieved using multiple approaches. Staff meetings aimed at achieving restraint reduction are one potential approach. • Staff (and children) within services need organisations to commit to enabling staff participation in individual and group de-briefing to discuss their role in restraint and its reduction.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
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Acknowledgements We would like to thank Peter McGill, Co-Director, Tizard Centre who supervised the research which was conducted as part of the requirements for MSc in Intellectual Disabilities.
References Allen, D. (2011) Reducing the Use of Restrictive Practices with People Who Have Intellectual Disabilities. BILD publications, Kidderminster, UK. Bullard, L., Fulmore, D. & Johnson, K. (2003) Reducing the Use of Restraint and Seclusion. Promising Practices and Successful Strategies. CWLA Press, Washington, D.C., USA. Colton, D. (2004) Checklist for Assessing Your Organization’s Readiness for Reducing Seclusion and Restraint. Commonwealth Center for Children and Adolescence, Staunton, VA, USA. Department of Health (1991) The Children Act 1989 Guidance and Regulations. Volume 4: Residential Care. Department of Health, London, UK. Department of Health and Department for Education and Skills (2002) Guidance for Restrictive Physical Interventions: How to Provide Safe Services for People with Learning Disabilities and Autistic Spectrum Disorder. Department of Health, London, UK. Donat, D. C. (2003) An analysis of successful efforts to reduce the use of seclusion and restraint at a public psychiatric hospital. Psychiatric Services, 54, 1119–1123. doi:10.1176/appi.ps.54.8.1119. Emerson, E. (2002) The prevalence of use of reactive management strategies in community based services in the UK. In: Ethical Approaches to Physical Interventions Responding to Challenging Behaviour in People with Intellectual Disabilities (ed. D. Allen). BILD Publications, Kidderminster, UK. Harris, J. (1996) Physical restraint procedures for managing challenging behaviour presented by mentally retarded adults and children. Research in Developmental Disabilities, 17, 99–134. HM Chief Inspector of Prisons (2012) Report on an unannounced short follow-up inspection of HMYOI Ashfield (11–13 October 2011). Available at: http://www.justice.gov.uk/publications/ inspectorate-reports/hmi-prisons/prison-and-yoi/ashfield (last accessed 11 May 2012). Huckshorn, K. (2004) Reducing seclusion and restraint in mental health settings: core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42, 22–33. LeBel, J. & Goldstein, R. (2005) The economic cost of using restraint and the value added by restraint reduction or elimination. Psychiatric Services, 56, 1109–1114.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., Weeks, M., Harper, G., LaFlair, L. & Sudders, M. (2004) Child and Adolescent Inpatient Restraint Reduction: A State Initiative to Promote Strength-Based Care. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 37–45. Liberman, R. P. (2011) Commentary: interventions based on learning principles can supplant seclusion and restraint. The Journal of the American Academy of Psychiatry and the Law, 39, 480–495. Lindsay, M. & Hosie, A. (2000) The Edinburgh inquiry – recommendation 55. The independent evaluation report. University of Strathclyde and the former Centre for Residential Child Care. McGill, P., Murphy, G. & Kelly-Pike, A. (2009) Frequency of use and characteristics of people with intellectual disabilities subject to physical interventions. Journal of Applied Research in Intellectual Disabilities, 22, 152–159. Mohr, W. K., Petti, T. A. & Mohr, B. D. (2003) Adverse effects associated with physical restraint. Canadian Journal of Psychiatry, 48, 330–337. Morgan, R. (2004) Children’s Views on Restraint. Office of Children’s Rights, Commission for Social Care Inspection, Newcastle upon Tyne. Nunno, M., Holden, M. & Tollar, A. (2006) Learning from tragedy: a survey of child and adolescent restraint fatalities. Child Abuse & Neglect, 30, 1333–1342. O’Halloran, R. & Frank, J. (2000) Asphyxial death during prone restraint revisited: a report of 21 cases. The American Journal of Forensic Medicine and Pathology, 21, 420–422. Petti, T. A., Mohr, W., Somers, J. W. & Sims, L. (2001) Perceptions of seclusion and restraint by patients and staff in an intermediate-term care facility. Journal of Child and Adolescent Psychiatric Nursing, 14, 115–127. Pilling, N., McGill, P. & Cooper, V. (2007) Characteristics and experiences of children and young people with severe intellectual disabilities and challenging behaviour attending 52-week residential special schools. Journal of Intellectual Disability Research, 51, 184–196. Steckley, L. & Kendrick, A. (2007) Young people’s experiences of physical restraint in residential care: subtlety and complexity in policy and practice. In: For Our Own Safety: Examining the Safety of High-Risk Interventions For Children and Young People (eds M. Nunno, L. Bullard, D. M. Day). CWLA Press, Washington, DC, USA. Weiss, E. M., Altimari, D. & Blint, D. F. (1998) Deadly restraints. Hartford Courant.
doi:10.1111/cch.12193
The impact of restraint reduction meetings on the use of restrictive physical interventions in English residential services for children and young people R. Deveau* and S. Leitch† *Tizard Centre, University of Kent, Kent, UK †Leitch Consultancy, Appin, Argyll, UK Accepted for publication 21 August 2014
Abstract
Keywords challenging behaviour, child care, reflective practice, residential and respite care Correspondence: Roy Deveau, Tizard Centre, University of Kent, Giles Lane, Canterbury, Kent CT2 7LZ, UK E-mail: [email protected]
Aim The aim was to examine the impact of post restraint reduction meetings upon the frequency and restrictiveness of restraint use in English children’s residential services. Background Attention has been drawn to the misuse, overuse and safety of some techniques used to physically restrain children in residential services. Successful interventions to reduce restraints have been reported, mostly from the USA. Results Demonstrate a significant overall reduction in both, frequency and restrictiveness of restraints; the greatest percentage decrease in the most restrictive floor restraints. Whilst five services reduced both frequency and restrictiveness, five services showed some increases in frequency and/or restrictiveness of restraints employed. Conclusions Restraint reduction is most effectively reduced through employing multiple strategies and that post restraint reduction meetings maybe one useful component. Organisations seeking to promote restraint reduction meetings need to allocate sufficient priority and resources to support these.
Introduction Public and professional attention has been drawn to suggested misuse, overuse and safety of some techniques used to physically restrain children in residential services. Government guidance in England states that ‘reasonable’ restraint use should only be as a ‘last resort’ to prevent children harming themselves, harming others or damaging property (Department of Health 1991). Subsequent guidance also recommends that staff working in children’s services should be trained in approved restraint techniques and organisations monitor the use of such techniques (Department of Health and Department for Education and Skills 2002). This paper uses the term restrictive physical interventions (RPI) and restraint interchangeably. One commonly used definition of RPI states:
© 2014 John Wiley & Sons Ltd
Restrictive physical intervention refers to the actions by which one person restricts the movement of another. (Harris 1996, p. 20). Children living in residential settings, away from their families, do so for a wide variety of reasons, e.g. having offended or a wide variety of social/emotional needs, such as intellectual disabilities or mental health problems that families cannot meet. Widespread use of restraint has been reported for children in some youth justice services (e.g. HM Chief Inspector of Prisons 2012). In other residential settings, e.g. care homes and hospitals, evidence suggests that around half of children admitted are subject to physical restraints, including children with learning disabilities and challenging behaviour (Emerson 2002; McGill et al. 2009) in general care homes (Lindsay & Hosie
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2000) and in residential schools (Pilling et al. 2007; McGill et al. 2009). For example, of 156 pupils exhibiting significant challenging behaviours, in nine 52-week residential schools, 69% had experienced RPI at least annually with 18% experiencing this daily and a further 19% weekly (Pilling et al. 2007). Restraining children may lead to physical and mental harm for children subject to such practices. For example, of 142 restraint-related deaths in the USA (Weiss et al. 1998) 37 were children (Nunno et al. 2006). Some restraint positions; prone floor restraint, wraps and basket holds carry risk of positional asphyxia (O’Halloran & Frank 2000; Nunno et al. 2006). Children may be particularly vulnerable to emotional harm or traumatization if forcibly held by adults while in care, especially children who have experienced previous abusive trauma (Mohr et al. 2003). Restraint is distressing to witness and many children subject to physical restraint describe feelings of sadness, guilt, anger, claustrophobia and panic. Negative emotions are felt particularly, if staff are seen as using unnecessary force and/or causing pain (Petti et al. 2001; Morgan 2004; Steckley & Kendrick 2007). However, some children report positive impacts from being restrained e.g. made them feel safe and cared for (Steckley & Kendrick 2007). The problems associated with restraint use in children’s residential services led to interventions designed to achieve restraint reduction (e.g. Bullard et al. 2003; LeBel et al. 2004; Allen 2011). The Child Welfare League of America (Bullard et al. 2003) reported reductions of mechanical/physical restraints or seclusion within five children’s services, including a school, and a psychiatric hospital, using leadership and organizational change, data monitoring, staff development and policy/procedural change. Additional positive outcomes may be linked with reduction of restraint, e.g. lower staff sickness and injuries (LeBel & Goldstein 2005). However, organizational supports for staff and children to develop alternatives to RPI are required (Liberman 2011). Achieving restraint reduction probably requires multiple strategies including: leadership and organizational change, monitoring use of RPI to inform practice, workforce development, extending consumer roles/ participation, staff debriefing and external review (Colton 2004; Huckshorn 2004; Allen 2011). Individual debriefing of staff following their involvement in restraint use in recommended in UK guidance. The restraint reduction meeting (RRM) is a variant of de-briefing, a team meeting of staff, led by a manager or senior practitioner, to consider alternatives to restraint following its use. Reduction in the use of seclusion and restraint has been reported in adult services following the introduction of RRM (Donat 2003). However, no reports of RRM in children’s services was found.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
Method A longitudinal pre–post-intervention design examined the impact of an intervention RRM upon the frequency and restrictiveness of RPI in children’s services in England. Ethical approval was gained from the University of Kent and the Association of Directors of (local authority) Children’s Services.
Settings Participating services/organisations were recruited through an advertisement in the National Centre for Excellence in Residential Childcare website. Of 30 potential services that expressed an interest 10 participated. A variety of reasons for nonparticipation included: staff changes, service closed, changes in client group or difficulty in assuring data collection. The researcher, second author, visited all services to explain the study and assess suitability to participate. The main contact in services was the service/home manager or behaviour consultant. Inclusion criteria for participation were: the service was residential, using some RPI on a regular basis, did not currently conduct RPI reduction meetings and the young people, care staff and parents agreed to take part in the study (Table 1). Data were collected for different periods because of the diversity of service configuration, e.g. service P a residential school was closed at weekends. Pre-intervention data were collected on the use of RPI for 3 months from eight services, for 5 months from service A because it was used to pilot the research procedure and for 7 weeks for service P where a long school holiday limited data collection. Service differences also affected the duration of data collection following commencement of RRM. Postintervention data were collected from six services for 6 months, for 4 months from two services (A and M) and for 5 months for service C; 9 weeks of post-intervention data were collected from service P. Frequency data reported are mean per month/week. To ensure consistent data for the two training packages, six categories were developed to record the level of restrictiveness of restraint employed see Table 2.
The intervention Following baseline data collection the researcher revisited each service and conducted a standardized workshop to introduce the concept and conduct of the RRM. The 2-h workshop covered, purpose of and criteria for the RRM, possible attendees, outcomes and actions of the meeting and recording of the meeting. Opportunity to practice completion of the RRM form, ask questions and discuss potential problems was provided. Services were expected have a RRM within 72 h of every
Voluntary One Local Authority Children’s Social Services Department
One large voluntary organisation
Voluntary
A C D E
I L M N O
P
Residential service of a term time residential school
Children’s home Children’s home Children’s home Children’s home Children’s home
Residential short break (10–18) Children’s home residential full-time Children’s home residential full-time Children’s home residential full-time
Type of service (age group – years)
Behaviourally & Emotionally disturbed
Looked After Children – behaviourally and emotionally disturbed (BESD)
Learning Disability Looked After Children – generic
Characteristics of service users
10
5 2 2 4 6
5 5 5 5
No. of places
10
9 8 8 8 10
7 11 11 11
No. of staff (FTE)
Proact-Scipr-UK
Proact-Scipr-UK
Proact-Scipr-UK GSA General Services
Behaviour support training package
Touch support. Front deflection
Proact-Scipr-UK
2-person
Friendly come along (1 staff)
1-person escort. Front arm catch. Front approach prevention
Friendly come along (2 staff) Standing figure of four
2-person escort
One or two staff on either or both sides of a child holding the child’s arms sometimes used to walk the child to another destination
1-person
Floor hold. Pick up from floor
Supine (face up) or prone (face down) child is held on the floor with staff holding legs and arms. Usually 3 or 4 staff involved Supine Wraps: one staff is positioned behind the child either seated or standing holding the child’s arms across their chest Hug wrap
Seated figure of four The wrap
Floor holds
Seated holds and wraps
Other planned or not
Seated holds: one or two staff sit beside/or either side of a child usually holding them by having their arms around the back of the child holding the child’s arms on the opposite sides. Sometimes staff may place their legs over the child to prevent the child from moving.
General Services Association (GSA)
Minimum
Category of interventions (1–6) Description of intervention
Table 2. Physical intervention categories mapped for different training packages
All services provided training for staff in behavioural management, including physical interventions. Training was provided by either General Services Association (GSA) ([email protected]) or Proact-Scipr-UK (http://www.proact-scipr-uk.com). FTE, full-time staff equivalents.
Provider organisation
Service code
Table 1. Details of participating services
Reducing restraint in children’s and young people’s services 589
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
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RPI category
Pre-intervention
Post-intervention
Mean change
1 (minimal holding) 2 (one-person escort) 3 (two-person escort) 4 (seated holds) 5 (floor holds) 6 (Other) Totals Overall means (SD)
8.8 21.6 17.5 20.6 16.9 4.5 89.9 14.9 (6.8)
2.1 13.4 14.7 15.2 8.6 7.3 61.3 10.2 (5.0)
−6.7 −8.2 −2.8 −5.4 −8.3 +2.8 −28.6
RPI employed. Sources of advice and support for the manager on positive behaviour support or additional professional expertise were also identified during this workshop if they were needed or requested. Separate information was distributed for the young people, staff and professionals involved with the children and parents/carers. Key workers were supported to explain the study to children and the study was discussed in staff and in children’s meetings. An information guide to RRM was provided for managers. Following workshops, the researcher provided ongoing support through phone contact, email and personal visits; no visits were undertaken to services (C, D and E) one visit to services (I, L, M, N and O) two visits service A and three visits to service P. The service manager, senior manager or behavioural specialist collected and submitted data.
Measures The following data were collected from services, monthly or weekly (from service P) on separate incidents of RPI (incident forms): • Child code (each child was given a code by the service to ensure anonymity); • The type specified was the name given to the type of restraint by the organisation that had provided the training, e.g. basket hold, supine restraint, two person escort. The restrictiveness of physical intervention was grouped into categories by the researcher: 1 minimum force used, 2 one-person restraints, 3 two-person restraint, 4 seated holds, 5 wraps and floor restraints, and 0 other; • Length of time RPI was used. Incident forms also had room for a brief description of the event leading up to the incident. In cases where more than one RPI was involved in the same incident, often a progression directly from one to the other, these are recorded as two restraints, e.g. if a young person was escorted by two people
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
Table 3. Mean monthly frequencies in six restrictive physical interventions (RPI) categories for 10 services pre- and post-intervention
through the living room and then held sitting on the sofa this is recorded as a 3 and a 4. Completed incident forms were emailed or posted to the researcher monthly or weekly. Incident form data were only entered into the analysis if the child continued to receive support, newly admitted children or those who moved were excluded (see Table 4). Only 57 RRM forms were returned (see Discussion). The researcher was able, through follow-up with services, to conclude that post-incident meetings were usually held when RRM forms were not completed. To assess the coding reliability of restrictiveness of physical intervention (PI) employed, as described by services and subsequently categorized by the researcher, just over 10% of incident forms were coded blind by three other research students at the university department supervising the research. Overall agreement between the researcher and others was 95.3%. Any incident forms with unclear information were followed up by the researcher and on two occasions excluded from the study.
Results Overall results in Table 3 show reductions in use of all categories of PI except for the ‘Other unplanned or planned’ category. The greatest decrease is in the most restrictive floor restraints. The reduction in total RPI use over all categories was 31.6%. A paired samples t test on overall means was statistically significant [t = 2.759 (d.f. = 5) exact P = 0.04]. The use of restraint varied widely within participating services (see Table 4). The restrictiveness scale was calculated from the monthly PI categories by counting each category as a numerical item, e.g. a category 2 (one-person hold) was scored as two on the scale and a category 5 (floor hold) was scored as five on the restrictiveness scale. For example, two RPI, a oneperson hold and a floor restraint would be reported as 2 on the frequency totals and 7 in the restrictiveness totals. The ‘other’ RPI category was scored on the frequency measure but not scored on the restrictiveness scale. Services A, C, E and M demonstrated reduction in frequency and restrictiveness of RPI employed. Service L had a low use of
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Table 4. Frequency and restrictiveness of restraint employed in services, mean per month/week (Number of children subject to RPI) and number of incident forms returned/per service A C D E I L M N O P
(7) (3) (1) (4) (3) (1) (2) (2) (4) (8)
34 8 30 31 153 3 13 13 47 251
Frequency of all RPI employed total (mean per month)
RPI restrictiveness scale mean per month
Pre-intervention
Post-intervention
Pre-intervention
Post-intervention
39 (7.8) 11 (3.7) 11 (3.7) 26 (8.7) 68 (22.7) 3 (1.0) 18 (6.0) 4 (1.3) 30 (10.0) 168 (24)
12 (3.0) 0 (0.0) 28 (4.7) 22 (3.7) 151 (25.2) 2 (0.3) 6 (0.86) 12 (2.0) 60 (10.0) 177 (19.7)
15.4 15.3 13.3 27.6 72.7 1.0 9.7 3.0 21.3 72.4
6.0 0 16.0 12.3 58.7 0 1.6 5.8 24.7 80.0
Statistics for service P refer to weeks rather than months. RPI, restrictive physical interventions.
RPI at baseline and stopped using RPI. The remaining five services demonstrated little difference in RPI use: Service I demonstrated a small increase in frequency but reduced restrictiveness of RPI, services O and P showed no change or a small decrease in frequency but an increase in the restrictiveness of RPI, services N and D showed small increases in both frequency and restrictiveness of RPI.
Discussion Limitations The current study has significant limitations. First, limited data on intervention fidelity, RRM was not monitored so the content or consistency of these meetings is uncertain, e.g. in some instances of RPI use they may not have been held. Second, no assessment on the reliability of level of RPI recorded by staff on incident forms was possible, leading to potential data drift in recording by staff, aware of the research process and purpose. Third, confounding variables were not assessed, e.g. the training and support for frontline staff or the quality of leadership. Fourth, the intervention period was limited and may not reflect the potential of RRM/extended de-briefing. Lastly, applying these results more generally, from self-selected services, is not to be done uncritically. However, the variability in outcomes provides some ‘face validity’ to the results.
Implications The current study sought to examine the independent impact of RRM in reducing RPI within complex service environments. The limited overall significance and variability in results suggests that other factors were important. For example, leadership in services
that choose to participate and additional external review by the researcher (which varied in participating services) may have been influential. The use of multiple strategies in a wide variety of contexts, make valid conclusions about the effectiveness of particular components difficult (Allen 2011). The role of RRM in reducing restraint and their relationship to other possible interventions in multi-component approaches requires further research. The current study suggests that services and organisations are all different and that the model of RRM must be flexible to meet the needs of particular service settings. Finding time to organize and conduct RRM was a significant barrier. Some services conducted RRM as part of team meetings or during handovers. RRM may be especially difficult to manage during periods where there are high levels of incidents. The current study suggests the importance of organisations allocating resources and priority to these activities.
Key messages • Restraint is associated with significant problems, including death and continues to be used in some services for children with significant frequency. • Reduction in the frequency and/or restrictiveness of restraint employed in services is an important policy goal and is probably best achieved using multiple approaches. Staff meetings aimed at achieving restraint reduction are one potential approach. • Staff (and children) within services need organisations to commit to enabling staff participation in individual and group de-briefing to discuss their role in restraint and its reduction.
© 2014 John Wiley & Sons Ltd, Child: care, health and development, 41, 4, 587–59 2
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R. Deveau and S. Leitch
Acknowledgements We would like to thank Peter McGill, Co-Director, Tizard Centre who supervised the research which was conducted as part of the requirements for MSc in Intellectual Disabilities.
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