What is restrictive practice?

‘Restrictive practice’ and ‘restrictive interventions’ describe the same thing, the RCN’s clinical guidance says. They refer to when a patient is made to do something they do not want to do, or when they are stopped from acting in a way they wish to.

Restrictions should only be considered when there is an immediate risk of harm to the individual or another person. Yet staff are using restrictive practices in everyday scenarios and infringing patients’ human rights without realising it, say experts.

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

Recognising and reducing use of covert restrictive practices

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 advisor 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, restrictions may be imposed on patients so staff can get their work done more quickly, especially in areas that are understaffed. ‘Nursing is very 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 the samples off before it gets very busy. But the patient might want to go off the ward then.

‘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 says entire multidisciplinary teams (MDTs) can be responsible for unintentionally restricting patients. ‘Look at polypharmacy. Patients can become severely constipated when they are on a lot of medication,’ he says.

‘They are then not comfortable enough to walk around and hat’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.’

What does the law say about restrictive interventions?

Nurses need to know about the European Convention on Human Rights (ECHR), which was incorporated into UK law through the Human Rights Act (1998).

Section 3 of the ECHR enshrines in law individuals’ right not to be treated in a degrading way, for example, by not being allowed to eat at certain times or being subject to measures that control behaviour, such as restricted use of television.

Section 8 gives individuals the right to respect for private and family life. Nurses need to be aware of this if they are limiting contact with a patient’s family and friends or being inflexible with visiting times.

It is possible to deprive a person of their liberty if they lack capacity to consent. The Mental Capacity Act (2005) allows for Deprivation of Liberty Safeguards (DoLS) to be put in place if hospital or care home patients meet strict assessment criteria. In these cases, care plans should detail any restrictions needed and why they are in a patient’s best interests.

Leigh Day law firm associate solicitor Catriona Rubens says: ‘It’s important to note that DoLS do not apply to all restrictions. They are situation specific. So just because there is a DoLS in place for a patient, it doesn’t automatically give health professionals the right to restrict that patient’s movements or physically restrain them.

‘Sectioning under the Mental Health Act is totally separate to DoLS. It can get complicated if there is an interplay between a DoLS and restriction under the Mental Health Act. I would recommend the Oliver McGowan mandatory training programme to health staff working in all areas.’

The human rights of children and people with disabilities are protected by the United Nations Convention on the Rights of the Child (UNCRC) and the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). These are treaties ratified by the UK.

Source: Leigh Day associate solicitor Catriona Rubens and RCN senior nurse in professional practice Rosaline Kelly

Restraint in mental health and learning disability nursing

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 it’s hospital policy. But it’s often not. The actual reason will be that it has worked like that for a long time. Ironically, restricting the patient’s access to drinking water will be the thing that goes against policy.

‘Restrictive practice covers so many things and you’d need to base consequences on context. In this case, you would want to educate the staff member and recognise there need for culture change in that particular place.’

Associate solicitor Catriona Rubens, of law firm Leigh Day, specialises in abuse and human rights claims, with an expertise in restrictive practices. She says 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. For example, if staff in the emergency department see a person with learning disabilities who is in distress, they may assume that person needs to be held down for cannulation.

Restraint gloves are among the physical interventions used in healthcare settings

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‘But you can act to calm them down so they are able to give consent, get family input and check their communication passport. Simply taking them to a quieter space could help.’

When restraint becomes a breach of human rights

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 adds 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 can also be 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 patients 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.’

Dr Teece says MDTs planning together is a key factor in reducing restrictions. ‘In ITU, sometimes a consultant would decide to reduce sedation too quickly, without communicating with the MDT. The patient would then become agitated, and one nurse would be 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 back up again. That is a lack of good communication and planning.’

Restraint in pressured settings

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

‘It’s about perceptions too. 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.’

Edge Hill University professor in child literacy Lucy Bray, who worked in acute children’s nursing for more than 25 years and whose research contributed to the United Nations’ Sustainable Development Goals in good health, 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.’

How to do things differently

Due to over-reliance on restrictive practices across settings, the RCN published its Three Steps to Positive Practice guidance in 2017. It was revised in June and gives nurses a framework to consider before using any form of restriction.

To enable positive practice, it says that nurses should plan restrictive interventions and ensure they have exhausted all other approaches. Safeguards should be implemented – such as a legal rationale and documented discussions across teams – to ensure the intervention is in the person’s interests, and this should be reviewed regularly and removed as soon as possible (see box, left).

Three Steps to Positive Practice: your guide to the framework

Picture credit: iStock

Step 1: Consider and plan

Consider if the intervention limits the person’s movement or daily activity, results in the loss of objects or activities the person values, or requires the person to engage in behaviour they would not choose. If the answer to any of these is yes, then this could be a restrictive intervention. There should be a multidisciplinary discussion on this and the use of less restrictive options should be considered first.

Step 2: Implement the safeguards

Discuss and document whether the intervention is in the person’s best interests, and issues related to their capacity and consent. Use a rights-based approach such as the FREDA principles – fairness, respect, equality, dignity, autonomy – when you plan the intervention, and ensure it fits under a legal framework.

Step 3: Review and reflect

Provide a timeframe for when the intervention will be reviewed. The restriction should last for the shortest time possible. You must also recognise the negative emotional impact of the intervention, not just for the patient, but for colleagues who have to implement it. Use opportunities for team reflective discussions where possible.

Source: Rosaline Kelly, RCN senior nurse in professional practice

RCN senior nurse in professional practice Rosaline Kelly, who co-authored the guidance, says it is beginning to have an impact.

‘Northern Ireland’s regional policy now requires nurses to consider these three steps when using restrictive practice,’ she says. ‘The framework is building momentum on the ground. It was needed, because so many health professionals had little to no understanding of their legal standing when using restrictive practices.’

The guidance does not mention the consequences for nurses who engage in restrictive practices. Ms Kelly says this is because the levels of restrictive practice vary, and consequences do too.

How to ensure interventions are used correctly

‘The first step is educating staff,’ Ms Kelly says. ‘Once people realise they have no legal authority to restrict, they want to change their practice.’

For instance, Ms Kelly says she spoke with a senior nurse working on a cancer care ward, who stopped patients leaving the ward because they were immunocompromised.

‘Once we had a conversation, she realised that she was depriving patients of their liberty with no legal authority to do so,’ she says.

‘The thing is, if you strongly advise most patients not to leave a ward and explain why, they will listen to you. They’re also more likely to engage with you, because you’re enabling their sense of control. It’s also legal to advise a patient in this way.

‘The problem – and where it’s legally a different situation – is when you impose a blanket ban on a cancer ward, and don’t give patients the choice to go down to the shop. They may be immunocompromised, but they still have the human right to make unwise decisions.’

Further information

RCN (2023) Three Steps to Positive Practice tinyurl.com/positive-practice-steps

Care Quality Commission (CQC) (2017) A focus on restrictive intervention reduction programmes in inpatient mental health services. tinyurl.com/restrictive-reduction-CQC

RCN: Restrictive practice tinyurl.com/restrictive-practice-RCN

CQC (2019) Our human rights approach for how we regulate health and social care services tinyurl.com/human-rights-CQC

The Restraint Reduction Network restraintreductionnetwork.org

The Restraint Reduction Network Training Standards tinyurl.com/restraint-network-standards

NHS – Health Education England (2023) Oliver McGowan Mandatory Training on Learning Disability and Autism tinyurl.com/mcgowan-mandatory-training

Oliver McGowan mandatory learning disability and autism training: what to expect rcni.com/learning-disability-training