In writing a new set of nursing curricula for the Future Nurse standards (Nursing and Midwifery Council (NMC), 2018) I was struck by an extremely brief statement in one of the annexes of those standards. The annexes list the skills and procedures that nurses must demonstrate they are able to perform safely. The statement that caught my eye was:
‘Recognise and respond to challenging behaviour, providing safe holding and restraint.’
The requirement is that evidence-based, best practice approaches are adopted.
The Future Nurse standards not only set out our pre-registration nursing curricula expectations but also now set the expectations for all current qualified nurses. Educational teams across the country, in NHS trusts and the wider range of healthcare providers, are considering what is required to upskill their workforce to meet these new standards. Previous standards (NMC, 2010) referred to the ability of all registrants to safely manage challenging situations but not to undertake safe holding and restraint.
One area I focus on in both my clinical and educational roles, is the provision of patient-centred care in acute hospital settings, in particular the improvement of care for those who have mental health needs. This is perhaps why the statement prompted my interest. Not all challenging behaviour is related to mental health needs and it is worth making clear early on that those with mental health needs are far more likely to be victims of violent and aggressive behaviour than to cause it (Pettit et al, 2013). However, the field of mental health, alongside learning disability, is where the majority of attention on restrictive practice and the drive for a reduction of its use has been focused; not least because of significant failures in care, for example, at Winterbourne View Hospital (Department of Health (DH), 2012).
Within mental health care considerable attention is given to how to prevent and manage challenging behaviour, which is not just related to the management of violence and aggression but also to behaviours that challenge in other ways such as avoidance of food and self-harm. There are clearly articulated evidence-based interventions available such as the Safewards model (Bowers, 2014) including the education needed for implementation (www.safewards.net). For learning disabilities nursing the excellent British Institute of Learning Disabilities (www.bild.org.uk) is at the forefront of positive behavioural support approaches to reduce restrictive practices such as physical restraint. However, it is less clear how to address the educational needs of pre-registration adult and children and young peoples' nurses using evidence-based, best practice approaches.
Understanding aggression
Patients in the general hospital have the potential to present with behaviour that challenges across the lifespan and across all health conditions, so there is a great deal of complexity to meeting this simple statement in Future Nurse. Nurses are also confronted by challenging behaviour from people in the hospital setting who are not their patients. The National Staff Survey 2018 reported that 14.5% of staff had experienced at least one incident of physical violence in the 12 months before completing the survey (Survey Coordination Centre, 2019). When we look at underlying reasons why people might present with such behaviour we need first to consider basic fight or flight mechanisms, where fear and anxiety is the basis of how we respond. Understanding this basic human psychological response will be fundamental to considering and assessing an individual and their reaction to us as practitioners, the care environment and its relationship to their healthcare needs. In contexts such as the emergency department, Ferns (2007) presented a useful model of theories of aggression as they might apply to that context. I have used this model in e-learning for the Royal College of Emergency Medicine about the management of violence and aggression.
Considering the guidelines
What are the evidence-based and best practice guidelines on which we should base our educational resources and policies for implementation? At present we have the National Institute for Health and Care Excellence (NICE) guideline for Violence and aggression: short-term management in mental health, health and community settings (NICE, 2015) and the principles laid out in the DH's (2014)Positive and Proactive Care document, the primary aim of which is that all restrictive practices including restraint should be used as an absolute last resort. When visited by the Care Quality Commission (CQC), hospitals can expect to be asked about physical and mechanical restraint use and for staff in areas of high levels of such restrictive practice to be asked about their training and competencies in the management of behaviour that challenges (CQC, 2018).
In the general hospital setting it is most common for the actual physical restraint to be a role undertaken by hospital security staff. Coupled with the philosophy of the NICE (2015) and DH (2014) guidance, namely the avoidance and de-escalation of challenging situations, it is interesting that the NMC has chosen to add to the cross-field annexes an expectation that nurses should be competent in safe holding and restraint. It is important that, if a patient in a general hospital is restrained or held for the protection of themselves or others, clinical staff who have a clear knowledge of the health conditions are present and can ensure that the person's health status is not impacted by any restraint. Decisions about restricting a person or restraining a person also encompass a wealth of ethical and legal issues including human rights and the requirements of mental health, mental capacity and case law. Education must also have a focus on these principles.
New training guidance has recently been published by the Restraint Reduction Network and should the nursing workforce in the general hospital setting be deemed to require competence in safe holding and restraint then those are the best practice guidelines that would need to be applied (Ridley and Leitch, 2019). We have also recently seen the publication of guidance specific to children and young people, which has a clear principle:
‘Wherever possible it [restraint] should be avoided: and proactive, preventative, non-restrictive approaches adopted in respect of behaviour that challenges’
My conclusion is that a renewed focus on behaviour that challenges though the implementation of the Future Nurse standards for pre-registration nursing students and registered nurses in the general hospital is timely. The focus should be to review and renew our efforts to support the reduction of restraint and safe holding through positive behavioural support. We must ensure that education is focused on how to identify and mitigate the triggers for behaviour that challenges, which will be unique to each individual patient.