Three Steps to Positive Practice A rights based approach when considering and reviewing the use of restrictive interventions ADVICE AND INFORMATION Consider Implement and plan the safeguards Review and reflect THREE STEPS TO POSITIVE PRACTICE Acknowledgements Co-authors Rosaline Kelly, Senior Professional Development Officer, Royal College of Nursing, Northern Ireland Dr Heather Hanna, Consultant Psychiatrist, Executive Committee Member, Royal College of Psychiatrists in Northern Ireland Adele Boyd, Independent Social Work Practitioner, Committee Member, Northern Ireland Association of Social Workers Moira Scanlon, Occupational Therapist Service Lead, Learning Disability and Mental Health, South Eastern Health and Social Care Trust Siobhan Rogan, Intellectual Disability CAMHS Manager & Advanced Practitioner, Southern Health and Social Care Trust Endorsed by: This publication is due for review in June 2020. 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This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. 2 ROYAL COLLEGE OF NURSING Contents Executive summary 4 Introduction 5 What makes a practice restrictive? 7 The three steps to positive practice 8 Outlining a rights based approach 10 Decision making 14 Professional accountability 14 Capacity to make decisions about care, treatment and support 14 Consent 15 Best interests 16 Advocacy 17 Positive practice 18 Evidence-based, therapeutic care 18 Positive and proactive approaches 20 A normalised and embedded culture of reviewing and reducing restrictive practices 24 Conclusion 26 Useful references and guidance 27 3 THREE STEPS TO POSITIVE PRACTICE Executive summary The 21st century requires fundamental changes changes and developments in legislation and in how health and social care professionals guidance regarding restrictive interventions and deliver care. One of these changes involves a rights based approach in a health and social embedding the delivery of care, treatment and care context. services in a rights based approach, which places the person at the centre of all we do. The challenge for health and social care professionals is to positively manage risk and deliver care whilst navigating the complex legal and ethical processes which must guide practice. This is particularly important in services, Consider Implement settings and situations where people may be and plan the safeguards subject to, or require the use of restrictive practices. It is encouraging to note the increasing number of examples of established positive practice in this area; however numerous Review and investigations and reports which have shown reflect historical failures and the need for ongoing reform must be acknowledged. In the current world of health and social care, professionals are ready to embrace new ways of thinking and the creation of a new culture which Three Steps to Positive Practice is a framework uses new language. A greater emphasis on early designed to help you as a health and social intervention enables an understanding of why a care professional to think about culture and person might behave in a certain way. practices and guide professional, ethical and legal decision making when considering the use Restrictive practices are sometimes necessary of potentially restrictive practices. Three Steps and could form part of health and social care to Positive Practice is a continuous and cyclical delivery. In this context it is essential that any process which requires a health and social care use of restrictive practice is therapeutic, ethical professional to: and lawful. • Consider and plan – consider if the planned This document was developed by a multi- intervention is a restrictive practice using disciplinary group based in Northern Ireland, the definition, consider other less restrictive involving the Royal College of Nursing, the Royal measures, and consider if the planned College of Psychiatrists, the Northern Ireland intervention is therapeutic in its intention; Association of Social Workers and the College of Occupational Therapists. It is designed to assist • Implement the safeguards – use a health and social care professionals who may rights based approach within professional be involved in practices where people in their accountability and legal frameworks to care may be restricted in some way, particularly ensure that any restrictive practice is used during the period of the local review of mental only when deemed to be in the person’s best health legislation and implementation of capacity interests; and, legislation. • Review and reflect – ensure that a regular The Three Steps to Positive Practice is a process and timely review of the use of a restrictive to guide professional practice and therefore also practice is built into a therapeutic plan to helpful to health and social care professionals meet the person’s needs, including reduction in Scotland, England and Wales. There are and/or removal of the restrictive practice as some differences in the legislation across the soon as is possible, and appropriate use of four countries and it is imperative that health professional reflection support systems that and social care professionals are aware of and consider the impact of the use of restrictive understand the legislation that is relevant to practices. their work. Health and social care professionals should also ensure that they keep up to date with 4 ROYAL COLLEGE OF NURSING Introduction Three Steps to Positive Practice should be used Historically, health and social care professionals at the points of assessment, implementation, have understood practices to be restrictive if evaluation and review, and in situations where they fell within the categories of physical or the use of restrictive practices have been in place mechanical restraint, with some also including for some time or are associated with a particular chemical restraint in their understanding of the environment. term. Many health and social care professionals only recognise the most obvious forms of Three Steps to Positive Practice provides restraint as being restrictive. guidance on the new way of thinking which will support health and social care professionals to Reports from health and social care regulators act differently. With an emphasis on a proactive, describe variance in understanding of the term evidence based and rights based approach to “restrictive practice”, across both hospital and practice, all health and social care professionals community settings, and the range of services for can ensure that wherever they are providing care, children, adults and older people. treatment and support, they are practising in the best interests of service users, and in accordance The Care Quality Commission (CQC) inspection with legislation and the requirements of their findings post-Winterbourne View described professional codes of conduct. In daily practice confusion and concern among staff in the the emphasis must include an understanding of awareness and use of restrictive practices. This why a person might behave in a way that presents resulted in an over-reliance by some providers on a perceived or actual risk, and/or in a way that physical restraint rather than positive behaviour challenges carers and staff. This understanding support and managing the environment to is vitally important in decision making processes remove or contain the triggers which could cause around the use of potentially restrictive someone to behave in a way which could be seen practices. as challenging. This is not a document that tells you how to A report by the Northern Ireland Regulation implement or when to implement a restrictive and Quality Improvement Authority (RQIA) in practice, nor will this document contain a 2014 in relation to the use of restrictive practices “list” of restrictive practices – that would be an noted a similar uncertainty. Staff described a impossible task. lack of understanding of restrictive practices, inconsistency in the use of restrictive practices, This document will be of use to any health and and an absence of robust and up to date social care professional who works in services guidance. There was also little understanding of where individuals may be subject