Prone restraint refers to a physical intervention where an individual is held face-down, or in the prone position, usually on the floor. Prone restraint carries serious risks. In mental health units in England, statutory guidance says there must be no planned or intentional prone restraint; check the current statutory guidance for your setting. In the context of health and social care, prone restraint is highly controversial due to associated risks and ethical concerns.
Historical Context
Prone restraint is not a new practice. Historically, institutions used it as a last-resort measure to manage violent or self-harming behaviours, especially in psychiatric settings. Over time, scrutiny has increased. Various incidents have highlighted the risks associated with prone restraint, leading to debates about its safety and ethics.
Risks Associated with Prone Restraint
There are significant risks linked to the prone position:
- Respiratory Issues: Restraint, especially face down, can seriously affect a person’s airway and breathing. Guidance says restraint must not compromise airway, breathing or circulation, and staff should monitor the person’s airway and condition and raise the alarm if concerned (see the statutory guidance).
- Circulatory Problems: Pressure on the torso and limbs can affect blood circulation, increasing the risk of circulatory complications.
- Psychological Trauma: Being restrained can cause emotional distress and long-term psychological trauma, especially for those with a history of abuse or post-traumatic stress disorder (PTSD).
- Physical Injuries: The force used to subdue someone can lead to physical injuries such as bruising, broken bones, or internal injuries.
Given these risks, the practice has been heavily criticised and subjected to stringent regulations.
Legal and Ethical Considerations
The law on restraint differs by setting and by nation. In England and Wales, section 6 of the Mental Capacity Act 2005 limits restraint to what is necessary and proportionate to prevent harm, and mental health units in England must also follow the Mental Health Units (Use of Force) Act 2018. Scotland and Northern Ireland have their own laws. Law and guidance emphasise the importance of using the least restrictive intervention necessary and prioritise the dignity and rights of the individual.
- Least Restrictive Principle: According to this principle, any form of restraint should only be used if no other less restrictive options are available.
- Information and Involvement: People should be offered a debrief after any use of restraint, and their wishes and views should be taken into account (see the statutory guidance).
- Accountability: Any use of restraint should be recorded and reviewed. Mental health units in England have legal duties under the Mental Health Units (Use of Force) Act 2018; follow your organisation’s procedure.
Alternatives to Prone Restraint
In mental health units in England, statutory guidance says there must be no planned or intentional prone restraint (see the statutory guidance). Various less restrictive alternatives can manage aggressive or self-harming behaviours:
- De-escalation Techniques: Training in verbal and non-verbal communication to calm agitated individuals.
- Environmental Adjustments: Modifying the environment to reduce stressors and triggers.
- Positive Behaviour Support (PBS): Understanding the reasons behind challenging behaviours and implementing positive methods to mitigate them.
Training and Competence
Staff should receive training in preventing and reducing restrictive practice, including de-escalation and positive behaviour support. In England, the statutory guidance refers to the Restraint Reduction Network national training standards (see the statutory guidance). Training typically covers:
- Risk Assessment: Understanding when and why prone restraint may be necessary.
- Techniques: Recognising early warning signs, using de-escalation, and knowing to release or reposition someone as soon as possible if they are restrained face down unintentionally. Follow your organisation’s procedure and the current statutory guidance.
- First Aid: Recognising signs of distress and providing immediate medical care if necessary.
- Legal and Ethical Guidelines: Familiarising oneself with the current regulations and ethical considerations.
The goal of such training is to ensure that staff can make informed decisions during a crisis, prioritising the safety and dignity of all involved.
Critical Incidents and Lessons Learned
Several high-profile incidents have spotlighted the dangers of prone restraint. These unfortunate events serve as valuable lessons, prompting reforms and improvements in practice.
- Case Studies: Reviewing specific cases where prone restraint led to severe injury or death can provide insight into what went wrong and how to prevent similar incidents.
- Policy Changes: Implementing new guidelines based on lessons learned ensures that such tragedies are less likely to occur in the future.
The Mental Health Units (Use of Force) Act 2018, which applies to mental health units in England, exists because the use of force can have serious and sometimes fatal consequences; see the statutory guidance for how it shapes practice.
Public and Professional Opinions
Public opinion and professional stances on prone restraint are varied. While some believe it is sometimes necessary, many argue for its complete abolition due to the associated risks.
- Professional Organisations: Professional organisations work to reduce restrictive practice. The Restraint Reduction Network, for example, developed the national training standards referred to in the statutory guidance; check their websites for current positions.
- Advocacy Groups: Various mental health advocacy groups campaign against the use of prone restraint, emphasising human rights and dignity.
Future Directions
The future of prone restraint in health and social care will likely see a continued push towards minimising its use.
- Research and Development: Continued research into less restrictive alternatives will provide more options for care providers.
- Policy Reforms: Ongoing reforms aim to tighten regulations and ensure greater accountability.
- Cultural Change: A shift in the cultural approach to managing challenging behaviours can lead to more compassionate and less restrictive practices.
Final Thoughts
Prone restraint in health and social care is a controversial practice with significant associated risks. Legal and ethical guidelines stress its use as a last resort, promoting less restrictive and more humane alternatives. Training, oversight, and continued reforms aim to reduce reliance on this practice, ensuring the safety, dignity, and rights of individuals in health and social care settings. By implementing these measures, the sector can move towards more compassionate and effective ways of managing challenging behaviours. Restriction in healthcare should prioritize the well-being and autonomy of the individuals involved. This includes considering individual needs, preferences, and cultural beliefs when developing care plans. By actively addressing the underlying causes of challenging behaviors and providing appropriate support, the use of restrictive practices can be minimized, leading to better outcomes for all involved. Additionally, promoting a culture of open communication and collaboration among healthcare professionals, individuals receiving care, and their families can further aid in reducing the use of restriction in healthcare.