Legal issues

Edge Hill University senior lecturer in learning disabilities James Ridley, a registered nurse of 26 years, says that varying definitions of ‘restriction’ can confuse some health professionals.

‘Broadly speaking, restrictive interventions tend to be applied to restrict individuals,’ he says. ‘Restrictive practices generally refer to blanket approaches.

‘Many nurses wouldn’t recognise that the way they work falls into these categories, and that’s a legal issue.

‘I heard about a former colleague telling a man with dementia that if he sat in a certain spot, his wife and children would come and visit him. This man believed that and sat there – and no one visited. The staff member doing this would not have realised this is a psychological restrictive intervention. Restriction doesn’t have to be physical.’

Restrictive interventions and practices can include seclusion, or environmental, physical, chemical, mechanical or psychological restraint, says the RCN’s clinical guidance.

‘I’ve heard of staff hiding patient call bells so they can’t ring at busy times, or stopping patients using specific areas at certain times,’ says Mr Ridley, who is an independent adviser at the Restraint Reduction Network, a charity working to reduce restrictive practices in health and social care settings.

‘These are blanket bans so they are restrictive practices. They work on a person’s emotions, and patients who need help become frightened of being told off.’

One major problem, he says, is that rather than being used when there is a danger present, nurses may impose restrictions on patients to get their work done more quickly, especially when areas are understaffed.

‘Nursing is task-orientated nowadays,’ he says. ‘When you are short-staffed it’s easier to stick to specific ward routines. At 9am, a nurse might want to take all their patients’ bloods quickly and send them off before it gets very busy. But the patient might want to go off the ward then.

Team responsibility

‘The response, because of high stress levels, might be: “You can’t leave now, you must wait until 10am.” Or, putting the bed rails up so a patient can’t move, because the place is understaffed and the nurse needs to get to other patients. These are physical and environmental restrictions. There are reasons why this happens, but patients’ legal rights come into it.’

Mr Ridley explains that entire multidisciplinary teams (MDTs) can be responsible for restricting patients unintentionally.

‘Look at polypharmacy,’ he says. ‘Patients can become severely constipated when they are on a lot of medication.

They are then not comfortable enough to walk around and that’s a physical restriction. But that’s not the intention of the prescriber or the person giving the drugs. There are different levels of restrictive interventions, and it is not always intended.’

Nottinghamshire Healthcare NHS Foundation Trust ward manager Nicola Shinn works in a high-secure learning disability service. She says that although learning disability nurses have a high level of knowledge about restrictive practices, some staff can confuse ward policies with long-established routines.

‘I’ve heard of unnecessary restrictions being imposed in certain places,’ she says. ‘Things like telling a patient they can’t fill a jug of water in the kitchen. The reason given will be that it’s hospital policy, but it’s often not. The actual reason will be that person or place has worked like that for a long time.

Bed rails can be considered a restrictive intervention

Picture credit: iStock

‘Ironically, restricting the patient from accessing drinking water will be the thing that goes against a number of policies. Restrictive practice covers so many things and you’d need to base consequences on the context. In this case, you’d want to educate that staff member and recognise there needs to be a change of culture in that particular place.’

Training standards

Associate solicitor Catriona Rubens, of Leigh Day law firm, specialises in abuse and human rights claims with an expertise in restrictive practices. She says that the Restraint Reduction Network’s training standards are known among mental health and learning disability nurses, but less so in adult and children’s settings.

‘Restrictions need to stop being seen as a standard part of someone’s medical treatment,’ she says. ‘Sometimes health staff can make assumptions that physical restraint will be necessary. If they see a person with learning disabilities who is in distress, they may assume that person needs to be held down for cannulation. But you can act to calm them down so they can give consent, get family input and check their communication passport. Simply taking them to a quieter space could help.’

Human rights laws

Ms Rubens says that if, in this situation, staff held the patient down before exhausting other options, it could be a breach of human rights laws.

‘That is our legal opinion,’ she says. ‘Restraint should be a last resort and used on an emergency basis only. If not, it could be considered excessive and disproportionate. That can amount to a breach of an individual’s human rights.’

She added that most of the legal cases she has dealt with have involved seclusion or physical restraint, and that often, patients were not aware that non-physical restrictive practices were unlawful – meaning complaints may not have been made in these cases.

University of Leeds lecturer in adult nursing Angela Teece, a former critical care sister whose research focuses on the use of restriction in intensive care units (ITU), says adult nurses need training on restrictive practice.

‘There are a lot of people with mental health issues in general adult settings,’ she says. ‘But we don’t get taught the law or proper procedures for safe holding. Mental health and learning disability nurses get this throughout their preregistration curriculum and after. They have a defined vocabulary for what they’re doing.

‘In ITU we use restriction a lot and yet it’s not part of our competency requirements. It’s reflected in the adult nurse vocabulary – we use infantilising language for serious things.

We will apply “mittens” to stop patients pulling lines out. These aren’t “mittens” but hand controls that physically restrain – and often don’t stop the lines coming out anyway.’

Planning together

Dr Teece says MDTs planning together is a key factor in reducing restrictions.

‘In ITU sometimes one consultant would decide to reduce sedation too quickly, and there hadn’t been any communication with the MDT. That patient then became agitated, and one nurse was stuck on their own shouting “I need help holding this patient down”. Then a whole team rushes in and holds down a frightened patient, and the sedation goes right back up again. That is a lack of good communication and planning.’

She adds that understaffing, nurse burnout and casual labelling of patients as ‘difficult’ during handover contribute to restrictive interventions being used unnecessarily.

‘If you’re exhausted from lots of shifts, you don’t have space to think critically,’ she says. ‘You’ll think “I can’t cope tonight, I want to stop anything bad happening”, and you put the sedation up for that patient and say it will help them “sleep” that night. That is chemical restraint. But we need to look at the factors that cause nurses to do this, rather than blame burnt-out individuals.

‘One of my studies looked at nurse handovers. If a nurse makes a negative comment about a patient during handover, such as “this one is aggressive”, you are more likely to go in that bit harder when you see that patient. That can result in you putting them in positions where they can’t move easily in bed, using psychological restraints or extra sedation, all because you are avoiding having an awful shift.’

Picture credit: iStock

Long-term impact

Edge Hill University professor in child literacy Lucy Bray, who worked in acute children’s nursing for more than 25 years, says the non-emergency use of restrictive interventions in children’s settings could come at a cost to public health.

‘There is a high likelihood of a long-term impact,’ she says. ‘Common sense would tell us that the trauma of this will probably affect their future engagement with health services. Why would you ever trust health professionals again? Even when they grow up, they’ll have those negative associations with us.’

Find out more

Care Quality Commission (2017) Mental Health Act: A Focus on Restrictive Intervention Reduction Programmes in Inpatient Mental Health Services.

Care Quality Commission (2019) Our Human Rights Approach for How We Regulate Health and Social Care Services.

NHS England (2023) The Oliver McGowan Mandatory Training on Learning Disability and Autism.

RCN (2023) Restrictive practice.

Restraint Reduction Network. restraintreductionnetwork.org

Restraint Reduction Network (2023) The Restraint Reduction Network Training Standards.

This is an abridged version of an article at rcni.com/restriction-and-rights

Hear more about restrictive practices from James Ridley at Nursing Live – a unique, free event for nurses, brought to you by RCNi. Sign up at www.nursinglive.com