The Department of Health Review:
Winterbourne View Hospital
Or,
Dogs and Goldfish.
I have just read the interim report from the Department of Health
and although good, there is a huge hole in the issue surrounding restraint (or
restrictive physical interventions).
This huge hole is not about whether restraint is used or what type of
restraint is used, but the fact that people are just using another name to
describe it, therefore it’s slipping under the radar of inspectors.
Let’s use an analogy
Imagine if you will, that I run an animal rescue centre and
we have government regulated space for only 10 Dogs. However, at this moment in time we have 100 Dogs. I have been told by the government inspectors
that I must reduce the number of dogs in my centre. In order to satisfy the inspectors, I can
either follow their rules or change my terminology so it appears the rules are being
followed. Therefore, I can either
re-house 90 Dogs somewhere else, or, more creatively, I can just re-label some
of the Dogs. In this scenario, let’s
rename them Goldfish.
My criterion for
changing the name from Dog to Goldfish is based purely on size. Therefore, if the dog is smaller than a
Labrador, it is now officially (in my centre) called a Goldfish. I’ve got 90 dogs smaller than a Labrador so
now I only have ten dogs and 90 “Goldfish”.
When queried by staff about why the small dogs are goldfish,
I respond by saying that they’re totally different because they’re totally
different. One is large and one is small so it stands to reason that they’re
not the same thing at all. Besides, in
our centre that’s how we classify dogs and goldfish. I realise that this doesn’t sound logical,
but wait until I get to the Seclusion/De-escalation story!
There are a couple of interesting points when looking at the
dog/goldfish scenario. The first being
that if I’m asked by my employers to count the number and types of dogs within
my organisation, I can say we have only ten dogs. Although in reality we have a hundred dogs
but only ten of them are larger than a Labrador. Therefore having relabelled the smaller dogs
as goldfish, we can say we have ten dogs and 90 (strange looking) goldfish.
Or perhaps another way of putting it would be to say we don’t
do restraint within our service because, before it gets to that, we use
guidance techniques to remove people to another area. Now, if I don’t know any different, then how
can I contradict someone who tells me this is the case?
Logically illogical!
A few years ago, we were asked to provide some training in a
private learning disabilities hospital for those rare times that physical
interventions were required. When we
arrived we were shown around the facilities which included a tour of the
grounds and the rather grand presentation of the Seclusion rooms. I kept my counsel and went through the
process of what they did and how they did it.
It appeared that seclusion was used in only 1% of situations and they’d
gone through the correct channels, registrations and training etc. to be able
to use seclusion rooms. I said to them,
although unhappy with the seclusion room as a method of management, we would
provide training as long as the people being put into seclusion were properly
monitored, it was used in conjunction with the Mental Health Act guidance, it
included a positive behavioural support plan and above all it was operated in
accordance with the current legislation.
It was only when we
started the training that it was presented to us that de-escalation or “de-esc”
was used 99% of the time and staff very rarely if ever used the seclusion rooms. In fact most of the staff trained hoped the Hospital
would stop using seclusion as soon as possible.
They seemed like a positive bunch that were forward thinking and willing
to change. It was only when we noticed
certain disjointed discussions around what they called “de-esc” that the penny
dropped. They weren’t discussing
de-escalation as an activity or a process of defusion. It was actually the room next to the
seclusion room (which was identical apart from not having a lock).
Therefore, de-escalation wasn’t what they did, it was where
they went. More importantly, in order to
get people to the room, they were “escorted”.
It transpires that this was done by having two members of staff put
wrist locks on the service user and one member of staff pushing the person
forward from behind. It was at that
moment, that my obsession with defining what was meant by restraint/seclusion/appropriate
strategies etc. was born!
So if it’s not a goldfish, then what on earth is it?
As a trainer, it’s often the case that people don’t know
exactly what restraint is; therefore they’d rather call it something else
because restraint sounds nasty and horrible.
Terms we’ve heard to describe activities we would define as restraint
have been – guiding, gentle holding, therapeutic holding, therapeutic guidance,
restrictive physical intervention, physical intervention, positive support,
positive guidance etc.
Therefore, if you don’t know whether you’re looking at a Dog
or a Goldfish and someone who sounds like they know what they’re talking about
says to you in a convincing voice –
“Well, of course it’s
a goldfish, it’s got a lovely wet nose, bushy coat and look at that wagging
tail it’ll even fetch a ball if you throw it”.
The end result is that all new staff coming in will
eventually just take for granted that what they’re looking at is a goldfish. With some organisations turning over 50% plus of
their staff every year, that’s a lot of new staff who think they’re looking at
a goldfish!
So why on earth call it a goldfish?
Because of the dislike of the word restraint, organisations
have tiptoed around the subject and are unwilling to address it. By renaming the process it often makes people
feel better about the services they provide.
If they’re doing less restraint, they must be doing a better job. In fact, this Department of Health report
identifies one of the main indicators of doing a better job as reducing levels
of restraint.
However, they’re missing the point. The terminology of restraint has less to do
with what you’re doing, than why you’re doing it. For me, one of the reasons that the problem
has arisen is because people equate restraint with being bad.
“It’s not a restraint
it’s a goldfish!”
Sorry
“It’s not a restraint;
it’s a least aversive positive handling physical guiding technique as part of a
wider behavioural support strategy”
The word or activity restraint itself isn’t bad; it’s the
purpose of the restraint that’s the issue.
If I restrain a child from running under a car on a busy road then very
few people would question how I did it or why, however if I perform the exact
same technique for stopping someone looking at me in a “funny way”, then quite rightly I’d be chastised
or possibly prosecuted.
It also needs to take into account the potential for
harm. Often we see restraint techniques
used which if someone slips/applies too much pressure or is simply too “enthusiastic”
then the potential harm is far greater than the outcome of the behaviour that
led to the restraint in the first place.
So, for example if my child is about to run into the road and get hit by
a car and I decide to stop this by running him over with a truck, perhaps the
purpose of my restraint is lost.
I have worked with some staff in the past who were horrified
to discover that when one of the people they support went to respite care, he
had both of his wrists dislocated during a restraint. What was the purpose of the restraint? Apparently it was because he was biting his
hand. So in order to keep him safe, they
dislocated both of his wrists! Now, we
know they didn’t do this on purpose, but, it does seem strange that the outcome
was made worse by the management of harm strategy.
So we now have three problems.
- Changing the name from Dog to Goldfish and therefore assuming that because we’ve changed the name to something different, means we don’t have to account for it anymore.
- We need to have purpose to what we are doing. They are intrinsically linked. If I don’t have an appropriate purpose for doing a restraint, then the easiest way of disguising what I do is to change how I describe it.
- The restraint shouldn’t create a worse outcome than doing nothing at all.
This report has made some great suggestions, my additional
one would be, if it’s restraint, then staff/organisations etc, must know that’s
what it is and account for it accordingly.
Moving Forward
We don’t just need to change terminology, we need to ensure
employees not only know what they’re doing, but why they’re doing it and be
trained appropriately in all areas. I
normally jump on my soapbox at this point and will do so again.
If someone understands why
someone is doing something, then they are more likely to approach them in a
positive way. All physical
interventions/restraint training MUST have this as part of their training. Trainers also MUST teach this before they
show you a neat guiding technique for moving someone who’s blocking a doorway
or being “awkward”.
Staff must be aware
that if they take hold of someone for whatever reason, and that person doesn’t
want to be held, it’s restraint!
Training in understanding is more important than techniques;
we need understanding because empathy is part of what makes it a “Caring”
organisation.
