The Department of Health (DH) (2014) set the agenda to reduce restrictive practice, initially within mental health services. There has been a general assumption that the term ‘restrictive practice’ relates to interventions such as the use of restraint (physical, mechanical or chemical), seclusion or rapid tranquilisation. However, further clarification confirmed that the term ‘restrictive practice’ relates to anything that potentially restricts a person's rights of choice, self-determination, privacy or freedom of movement (Whyte, 2016; Clark et al, 2017). It is becoming generally accepted that restrictive practices (such as strict ward rules) may bring about frustration, feelings of stigma and subsequent challenging behaviour that may lead to restrictive interventions (such as sedation or holding) (Clark et al, 2017).
The Care Quality Commission (CQC) (2017) confirmed the need for a reduction in the use of restrictive practices and stipulated that all providers must take note of the DH guidance (2014). Providers must have a strategy, policy and procedures for the management of patients who exhibit challenging behaviour and actively demonstrate that a holistic assessment has taken place. In addition, the use of positive behavioural support plans is recommended. Failure to comply with the CQC guidance will result in the commission acting against the provider (CQC, 2017).
Emerson (2001:3) described challenging behaviour as ‘culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities'.Challenging behaviour may differ from person to person, may or may not involve aggression to self, others or property, and may often result from the person's needs not being met or from the imposition of restrictions (Hext et al, 2018).
Following the CQC guidance (2017) the agenda for reducing restrictive practices and introducing alternative ways of managing challenging behaviour in mainstream adult nursing services has started to gain momentum (Hext et al, 2018; Xyrichis et al, 2018). There is a realisation that patients often exhibit challenging behaviours, not due to their mental health problem or intellectual (learning) disability, but because their needs are not being met. The situation is often complicated by authoritarian staff attitudes and behaviours, unnecessary ‘ward rules’ and a ‘zero tolerance’ policy. There are also issues regarding diagnostic overshadowing whereby, if the patient has a diagnosis of a mental health problem or intellectual disability, secondary symptoms remain unexplored and are attributed to the primary diagnosis (Hext et al, 2018; Xyrichis et al, 2018).
Application to children's services
Reducing restrictive practice in adult, mental health and learning disability services with the aim of limiting the occurrence of challenging behaviour is clearly being driven forward with the CQC (2017) agenda. It is therefore an ideal time to explore how restrictive practice relates to children's services, particularly for children or young people with learning disabilities or mental health issues. The role of the children's nurse in identification and minimisation of restrictive practices may routinely be undertaken without recognising or understanding how these may adversely influence a child or young person's behaviour.
The Children Act 1989 established the welfare principle that any interventions should be in the best interests of a child or young person, which was further developed in the updated version, The Children Act 2004. This requires any agencies that work with children to take all reasonable measures to ensure that the risks of harm to children's welfare are minimised and to take appropriate actions to address any concerns about a child's welfare. This should raise the question of approaches to restrictive practices (or restrictive interventions) and whether they are proportional, necessary or in fact in the best interest of that child or young person.
According to the Challenging Behaviour Foundation and Positive and Active Behaviour Support Scotland (2020), behaviour that is perceived as challenging can almost always be attributed to a trigger such as changes to a daily routine, with the child or young person's reaction to this potentially being their only way of communicating an unmet need. Nurses are therefore in a strong position to work in partnership with parents or carers to better understand the reasons behind such behaviour and aim to reduce the likelihood of it occurring in the first place by providing the most appropriate support at the right time.
NHS Improvement (2018) has highlighted that mental health service provision for children and young people remains significantly under-resourced despite the continued increase in identified cases. As a result of this lack of investment, the specialist child and adolescent mental health services cannot undertake the timely assessments and delivery of treatment it was set up to do, leading to widespread frustration (NHS Improvement, 2018). As a result of this, many children and young people presenting to emergency departments in acute mental health crisis are not assessed by a mental health specialist in a timely manner. In addition, they may be subject to unnecessary restrictive practices and interventions such as seclusion and one-to-one monitoring as a result of inexperienced and unsupported children's nurses working in an environment unsuitable for children or young people exhibiting challenging behaviour (Royal College of Emergency Medicine, 2017). Often those requiring a mental health assessment are routinely admitted unnecessarily overnight for assessment the following day, which is a restrictive practice in itself, and may not necessarily be in the best interests of that individual because it restricts choice, privacy and freedom of movement (Clark et al, 2017).
Inadvertently creating barriers/hospitalisation
Restrictive practice is shaped by culturally derived beliefs about rights of choice, self-determination, privacy and freedom of movement (Clark et al, 2017; Hext et al, 2018). These beliefs are consistent with empowerment, respecting personal autonomy, and the recognition of human rights, cited as core elements of family-centred care in children's nursing (Mikkelsen and Frederiksen, 2011). It could be postulated that children's nursing has a cultural orientation that is primed to recognise, prevent or reduce restrictive practices.
However, when a child is hospitalised the complexity of the landscape in which care happens may inadvertently create a culture where restrictive practices are created and exercised. The complexity of hospital environments reflects multiple levels of competing priorities and professional agendas, including balancing the individual expectations of children and their families and government policies impacting on care delivery. Professional expectations and increasingly blurred boundaries between roles potentially challenge the premise on which partnerships between individual nurses, children and their families are formed. Organisational responses to such complexity results in the creation of system policies and procedures that in turn frame nursing activity. Children's nurses must contextualise these competing agendas in order to achieve optimum person-centred care for an individual child and their family.
Hospitalisation can itself be considered a restrictive practice (Hext et al, 2018). Throughout the history of children's nursing, ongoing tensions between nurses and parents have been identified, and there is an ongoing critique of the challenges of implementing family-centred care, particularly for children with long-term conditions (Smith et al, 2015; McNeilly et al, 2017). Enduring themes cited as problematic include parents' expertise in care and the provision of education and information. A hospital admission can challenge the parent's sense of self-efficacy and confidence as they manage the profound differences in the perception of power and control over their immediate environment. Decision-making and participation in their child's care and perceived or actual assessment of their parenting skills by nurses and others may also have an effect. Uncertainty and the power differential experienced in hospital is reflected in language used by parents in a study into their experiences of making decisions for their disabled children and young people (McNeilly et al, 2017). In this article, parents were quoted as saying they felt they needed to ‘fight for my child’, that it was ‘difficult to challenge professionals’, and that they felt ‘vulnerable’ (McNeilly et al, 2017). Meeting the education and information needs of children, young people and their families provides a significant way to minimise restrictive practice. The role of the nurse as an educator and teacher for children, young people and families when enacted well can empower and enable and, conversely, can disempower and control when poorly undertaken.
In summary, the experience of hospitalisation is underpinned by social, cultural and political contexts that can potentially create possibilities for restrictive practices. Recognising aspects of hospital environments that have the potential to exacerbate or minimise restrictive practice is worthy of attention.
The way forward
Recent guidance from the Department for Education and Department for Health and Social Care (2019) focused on the promotion of a preventive approach to supporting children and young people whose behaviour challenges. Restrictive interventions, including restraint, in services catering for children and young people with learning disabilities, autism spectrum disorder and mental health problems could be reduced. However, although this guidance puts the child or young person's welfare at the centre, this could have been an ideal platform for exploring the concept of restrictive practices that may ultimately result in restrictive interventions (Hext et al, 2018) to highlight issues in everyday healthcare provision.
According to the Royal College of Emergency Medicine (2017), all children and young people with known mental health problems already in contact with services should have a realistic safety and coping plan that has been created with the child or young person and their family. The plan should aim to reduce the risk of crisis but is also able to address a crisis should it occur. The CQC (2017) has endorsed the DH (2014) in that all behavioural support plans should contain person-centred primary, secondary and tertiary interventions for the management of challenging behaviours. This method provides a scale of planned interventions for use at three different points of behavioural escalation, tertiary being the most serious. This is also applicable to a child or young person with a learning disability and those with an autistic spectrum disorder, who is at risk of crisis. A well written plan should effectively encompass a bio-psycho-pharmaco-social approach to assessment and management of care (Clark and Clarke, 2014). This should include the communication needs of the child and family, in addition to the current environment, which may have an impact on all concerned. If such plans are implemented in a timely manner, identified triggers should be minimised (Clark et al, 2017), in addition to frustration and anxiety in the child or young person and their families/carers being kept to a minimum.
A bio-psycho-pharmaco-social approach to the assessment and management of care in the form of behavioural support plans for adult male patients in a psychiatric intensive care unit was shown to reduce incidents of challenging behaviours and use of restraint and seclusion (Clark et al, 2017). This approach examines the patient from each of the four domains—biological, psychological, pharamcological and social—and studies the relationship they have with each other and within the current environment (Clark and Clarke, 2014). This work has been evaluated and successfully implemented across other specialties of nursing (Clark et al, 2020). The level of detail required for successful use of the model would appear beneficial in the care of children with complex presentations. By using this approach, possible trigger factors are identified, and a management plan developed to incorporate primary, secondary and tertiary interventions for the prevention and management of challenging behaviour. It is suggested that this approach could be transferable to children's nursing and yield similar results; however, workforce education, training and commitment would be core to its success.
Collaboration is the key to any successful child-centred care planning, which is especially evident when health professionals are reliant on children, young people and their families to identify what key triggers may cause significant disruption. This will also help identify how to best support the individual to settle as quickly as possible after exposure to a trigger. Johnson et al (2014) presented the findings of a small study of parents of children with autistic spectrum disorders and health professionals in an inpatient setting. The purpose was to facilitate an in-depth discussion of the meanings attributed to child behaviours and prevention strategies. Although recognising the importance of engagement between the parent and health professionals in undertaking an individual assessment of a child's trigger factors, one mother described not being routinely asked about her child's behaviour strategies when in the hospital setting (Johnson et al, 2014). One health professional described various approaches to reduce environmental stimuli such as limiting the number of people in the child's room at one time or dimming the lights in the hope that this would prevent challenging behaviours from occurring in this unfamiliar setting (Johnson et al, 2014). A child or young person with an autistic spectrum disorder often exhibits challenges with communication and socialisation, therefore changes in routine can lead to aggression, self-injury, extreme anger or frustration, as well as persistent non-compliance with everyday tasks or requests (McGuire et al, 2016). Thus it would seem vital that health professionals work in partnership with the parents, who are in the strongest position to give guidance on their child's individual needs.
It is suggested that, within a family-centred approach to the delivery of care in the inpatient environment, there needs to be consideration as to how parents, children and nurses negotiate roles and relationships (Coyne, 2015). Coyne's (2015) family-centred care study found that a lack of negotiation led to parents feeling stressed or abandoned, experiencing hidden expectations and unclear role definition. It was proposed that although families are willing to help with their child's care needs, they need clear guidance, information and support to be able to do so.
Parental strategies to limit disruption and potentially reduce the risk of challenging behaviour, such as planning activities for the time of day when their child is most receptive, attending events when less busy, and reducing their child's exposure to sensory stimuli (O'Nions et al, 2018), have proved successful. Through adherence to fixed routines with minimal disruption, parents reduced the likelihood of their child displaying challenging behaviour. However, once the familiarity and structure of the home environment is removed by an admission to a busy children's ward with rigid routines such as set meal and bed times, frequently changing staff and unscheduled tests; or the presentation to a potentially over-stimulating and unpredictable environment such as an emergency department, the control over these strategies is inevitably removed (O'Nions et al, 2018).
Perceived or enacted criticism is a concept highlighted by Neill and Coyne (2018) as a component that has the potential to negatively impact on the relationships between members of the healthcare team and family members. A hospital ward, for example, can potentially leave some parents or carers feeling disempowered as they are fully dependent on the multiprofessional team for information and involvement in decisions. This is particularly pertinent for those parents of children or young people with complex health needs who are managed independently in the home environment, or those with identified challenging behaviours (Oulton et al, 2015). This lack of recognition of the parent as the expert care giver could potentially be considered as restrictive practice, with parents often reluctant to instigate care for fear of doing the wrong thing.
One significant challenge is the conflicting advice given to parents regarding the most appropriate approaches to managing challenging behaviour in their children. Some experts focus on identifying triggers and promoting positive outcomes (Lucyshyn et al, 2015), others recommend the inclusion of behavioural consequences to encourage the child or young person to actively amend their behaviour before it reaches a level of challenge (Agazzi et al, 2013), which potentially could constitute restrictive practice. Alternatively, Singh et al (2007) place the emphasis on parental mindfulness in transforming the behaviour of their child.
Conclusion
The reduction of restrictive practices is an important national agenda item across all health providers and fields of nursing. In order to take this forward, greater understanding is needed by children's nurses of the impact that restrictive practices may have on children and their families. Education must cover some of the causes of challenging behaviour and the impact that restrictive practices, disempowerment, poor communication and less supportive attitudes have on children and families. Behavioural support plans, adopting a bio-psycho-pharmaco-social approach, may be useful in the assessment and management of care, especially when the child is likely to exhibit challenging behaviour. A pilot study is recommended in order that behavioural support plans utilising a bio-psycho-pharmaco-social approach can be fully explored in children's nursing.