Positive approaches to reduce restrictive practices in social care

Feeling what we say has been heard and understood and being in control of our life, has a massive impact on our behaviour. When this is not the case, we’re more likely to feel powerless and distressed and engage in behaviour that challenges others.

This will also be the case with the people you offer care and support to. Because of their circumstances, they too, may at times feel powerless to make changes in their lives and will say and do things that challenge others. It’s important to always treat people with compassion, dignity and kindness, and to try to understand the cause of any challenging behaviour.

Positive and proactive (or preventative) approaches are based on the principles of person-centred care:

• getting to know a person, respecting and valuing their histories and backgrounds, and understanding:
  • their likes and dislikes
  • their skills and abilities
  • their preferred method of communication
• understanding the impact of their environment on them and using this to identify positive and consistent ways to support
• feeding into and following care plans that set out a person’s needs, their well-being outcomes and how they’ll be supported to achieve them.

Developing good relationships is key, and positive and proactive approaches should be used at all times. They are essential when someone is:

• stressed
• distressed
• frightened
• anxious or angry

and at risk of behaving in a way that’s challenging to their safety and/or to the safety of others.

Positive approaches involve working with the person and key people in their lives to:

• try to understand what someone is feeling and why they are responding in the way they are
• where possible, make changes and intervene at an early stage to try to prevent difficult situations
• understand what needs to be planned and put in place to support the person to manage distressed and angry feelings

in a way that reduces the need for challenging behaviour and places restrictions on them.

There are a number of definitions of the term ‘behaviour that challenges us’ or ‘challenging behaviour’. Some focus on the seriousness of the behaviour, the length of time it goes on for, and the risks it presents to the individual, family, social care workers or others.

How we recognise behaviour that challenges can vary depending upon the frequency, severity, intensity, and risks of that behaviour. It may also depend on how the behaviour affects us and/or others around us. This may differ, as, for example, one social care worker may not mind if a person asks them the same question repeatedly, while another worker may find it difficult and stressful, and so may try to avoid spending time with them.

Behaviour that challenges may include behaviour that:

• is aggressive
• is anti-social
• is disruptive
• is isolating, such as withdrawal
• is repetitive
• is obsessive
• is verbally abusive
• puts the physical safety of the person or others in serious jeopardy, or are likely to seriously limit the person’s use of ordinary community facilities.

You will have your own examples but some of these behaviours could be:

• swearing
• threatening
• pushing, grabbing, scratching, biting and pinching
• spitting
• shouting or screaming for long periods of time
• sexually disinhibited behaviour such as exposing genitals, removing clothing and making sexual comments and gestures
• wandering
• banging of the head
• asking repetitive questions

It’s important to try to understand the meaning of this behaviour and what the person is trying to communicate. This may not always be possible straight away as the situation may need urgent action to keep the person or others safe.

Underlying causes could be:

• chronic or acute pain
• infection or other physical health issues
• sensory loss
• an acquired brain injury or other neurological condition
• communication difficulties
• environment
• fear and anxiety
• unhappiness
• boredom
• loneliness
• unmet needs
• demands
• change
• transitions
• recent significant events, such as the death of a family member
• past events or experiences
• abuse or trauma
• bullying
• over-controlling care
• being ignored.

However, reflection and discussion with family members, close colleagues and multi-disciplinary team members after the event or incident will help us develop a better understanding.

Restrictive practices are activities that stop people from doing the things they want to do or encourages them do things they don’t want to do. They can be obvious or subtle. They range from limiting choice to responding reactively to an incident or an emergency, or if a person is going to seriously harm themselves or others.

To reduce the use of restrictive practices, we need to understand how to use positive and proactive approaches.

John, a young autistic man, asks constantly to call his family and former friends. Some of them don’t want him to call every day. He becomes very distressed when they don’t want to talk to him and is verbally aggressive towards his social care workers.

A plan was agreed with him to make a list of his friends and family who mean a lot to him, and to agree a set time to call them. For example, he will call his mum at 6pm each day and a friend once a week on a Saturday after 7pm.

This has worked for John as he feels more secure having set times and his support staff can help him look at his calendar if he becomes distressed and wants to call at other times.

Although he doesn’t have the free access to the phone he wants, his stress levels have reduced, and his family and friends are happy to talk to him at the agreed times. He can now carry on having a good relationship with the people who mean a lot to him. This reflects a positive approach to supporting John.

The restrictive practice in this scenario was limiting the times John could use the phone.

Restrictive practices could also include more obvious actions such as those listed in Welsh Government’s Reducing Restrictive Practices Framework such as:

• physical restraint
• coercion
• chemical restraint
• environmental restraint
• mechanical restraint
• seclusion or enforced isolation
• long term segregation

They should only be used as part of an agreed behaviour support plan and should only ever be used as an immediate and planned response to behaviours that challenge or to take control of a situation where there’s a real possibility of harm if no action is taken.

Any act of restrictive practice has a potential to interfere with a person’s human rights. So all acts of restrictive practice must be lawful, proportionate and the least restrictive option available.

Restrictive practices must never be used to punish or with the sole intention of inflicting pain, suffering, humiliation or to achieve compliance. It is never lawful to use restraint to humiliate, degrade or punish people.

Key point

Restrictive practices, other than those used in an emergency, should always be planned in advance and agreed by a multi-disciplinary team and wherever possible, the individual, and included in their personal plan, behaviour support or behaviour management plan. They should always be recorded in an individual’s care plan.

The following scenarios show situations that social care workers may find themselves in. The scenarios cover a wide range of restrictive practices.

Some of the scenarios are more obvious than others, but as you go through them remember that in real life we do not work alone. Any decision to restrict a person should be based on discussions with others, including the person, their families and those who know them well.

When reading the scenarios, think about the following questions (you don’t need to record your answers):

• What type of restrictive practice do you think has been used?
• Do you think the use of the restrictive practice was intentional or non- intentional?
• Do you think this was the least restrictive option?
• Was the practice contrary to the rights of the person?
• Was the practice ethically or legally justifiable?
• Who should be involved in making the decision about the restrictive practice used?
• What other methods of working could have been used to reduce the need for restrictive practice?
• What steps could be taken to reduce the use of restrictive practice in the future?

Scenario 1: In a residential care home, a man’s glasses are moved out of his reach while he’s being supported with his personal care in the morning. He is without them until lunchtime.

Scenario 2: A young man with mild/moderate learning disabilities is out on a group trip to Thorpe Park. His case history indicates infantile and pre-school seizures, although he has not experienced anything recently. The group leader decides he is not allowed on any of the rides.

Scenario 3: In a day centre, a woman is left for several hours with her wheelchair seatbelt on to prevent her wandering.

Scenario 4: A woman who lives in a residential care home is regularly encouraged to return to spend time in her room alone because her singing upsets other residents.

Scenario 5: A man in his early 20s with learning disabilities recently lost his mother, who was his sole carer. Now living in supported accommodation, he wants a small tattoo on his arm – “MUM”. A social care worker approaches his line manager who tells him he will be suspended if he helps the man do this because of “health and safety”.

Scenario 6: Social care workers in a residential care home switch off the television in the communal lounge at 10.30pm to encourage people living there to go to bed.

Scenario 7: In a residential care home, an 87-year-old man living with dementia regularly gets up in the night and wanders around disturbing other residents. As he has been trying to climb over the bed rails fitted to his bed to get up, the care home team decide to place his mattress on the floor. He can’t get up from the floor and so has stopped wandering.

Scenario 8: Bedroom doors are routinely locked to stop people going back to bed in the day.

Scenario 9: Megan has dementia and can only speak and understand Welsh, she goes to day centre three days a week. No-one at day centre speaks Welsh so Megan cannot ask for help to use the toilet when she needs it or let people know when she’s thirsty.

Working in health and social care can be very rewarding, but like any job, at times, it can be difficult and demanding. Offering care and support to vulnerable people who may be distressed, frightened, angry, stressed, confused and who may display behaviours that challenge us can leave us feeling powerless, frightened, angry, anxious and out of our depth. It’s important to reflect on what is happening around you at these times, how you are feeling and the support you need.

When you have completed your induction, you will be able to learn more about how to reduce restrictive practices. We have a resource that you can use to gain more knowledge to help you with your work. Talk with your manager or mentor about this and they will help you use the resource.