The impact of restrictive interventions in a learning disability service

Recent high profile cases have drawn attention to the use of techniques used to control people with learning disabilities when they display challenging behaviour. These techniques are collectively referred to as restrictive interventions in this work and include physical restraint, medication and seclusion. The limited research available indicates that young males with learning disability with another diagnosis such as Autism are most likely to be in receipt of restrictive interventions and that restraint and medication are those most likely to be used. It was also identified that there is extensive conflicting and confusing terminology used in documents regarding restrictive interventions. The literature also highlighted that both staff and patients can suffer injuries as a result of using these interventions, additionally there is little research that focuses on the impact that restrictive interventions have on those central to the issue: the staff members and the patients. This thesis presents research undertaken that explores incidents of violence and aggression and other challenging behaviours in a learning disability service. The research took place in an NHS Trust and focuses specifically on the impact of restrictive interventions used to manage challenging behaviours, examining that impact on the service, the staff and the patients. The research is in three parts. Part one is a retrospective study of untoward incident documents to establish the number, nature and type of incidents that occur in the learning disability service and the type of restrictive interventions utilised by staff to deal with these incidents. It establishes who is involved in these incidents with regard to both staff and patients and any trends regarding when incidents happen. The second and third studies go on to qualitatively explore, using a phenomenological approach, how people feel about being involved in challenging incidents with particular focus on how they feel when restrictive interventions have been utilised. Study two focuses on the staff involved in dealing with challenging behaviours and implementing restrictive interventions and study three focuses on the patients with whom the restrictive interventions are used. In the quantitative study 312 incidents were recorded during the research period and identified that 248 of these incidents took place in one part if the service, the Assessment and Treatment Service. Of these incidents 123 were dealt with by Heath Care Assistants and staff from the non- professional categories. The largest number of incidents, 180 were classified as patient to staff assaults. The most common intervention utilised was an approach called passive restraint, closely followed by the use of medication and full restraint. De-escalation was only recorded on 5 occasions. However, of the 312 incidents 195 had no intervention recorded. A further interesting finding, that conflicts with much of the literature in this area is that a high proportion of the incidents involved female patients. Twelve staff were interviewed, six qualified nurses and six health care assistants, three males and three females in each group. Thematic analysis of the interviews produced six themes while the patient interviews produced three themes. The staff themes included staff beliefs about the nature of the patients and the incidents, role conflict, negative impact on staff, negative impact on patients, the significance of the team and preference for aversive techniques. Three male patients were interviewed and the themes identified from these interviews were them and us, overwhelming negative reactions; and understanding and insight. Some of the themes from the staff interviews were echoed in the patients interviews, specifically the ‘role conflict’ theme from the staff interviews and the ‘them and us’ theme from the patient interviews, which highlighted the destructive impact the use of restrictive interventions has on the therapeutic relationship. Both staff and patients also highlighted the negative emotional reactions they experience when involved in the use of restrictive interventions, which stay with them over long periods. Despite these negative emotions, staff discussed the significance of good team working and good leadership can have on them while patients showed understanding into why restrictive interventions are used. In a service that admits people who have been unable to be cared for in any other setting, in the period before staff can get to know them challenging behaviours will inevitably occur. These behaviours will need some sort of restrictive intervention to ensure the patient, staff and other patients are safe. To minimise the use of these techniques and their negative impact the following recommendations should be introduced. There needs to be improvement in the use of alternatives to restrictive interventions mainly around the use of de-escalation and PBS, debriefing should be introduced for staff and patients with robust training to underpin all of the above especially to HCA’s. In addition, there needs to be an improvement of recording of incidents and a standardisation of language used for restrictive interventions, with more research around the use of restrictive interventions and the impact it has on those central to the issue- the staff and patients