Studio III Position Document On
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The use of physical interventions in care environments should be viewed nearly always as a failure of a system. Physical interventions may sometimes be necessary in some cases but, they should not become a common response.
A Person-Centred approach to the teaching of Physical Interventions
Using words like person-centred and physical interventions in the same sentence would appear to be a contradictory. The Studio3 approach has always been based on developing methods that are not only safe and effective but also socially acceptable (McDonnell et al 2008; McDonnell & Jones 1999; McDonnell & Sturmey 1994). To us, Physical Interventions should be designed within an ethical, person-centred frame work.
Staff training in Physical Interventions cannot solve all the problems of challenging behaviour in care environments
Research demonstrates that staff training, on its own, is viewed as necessary but not sufficient for behavioural change to occur (Cullen, 1993). Service policies and support services are a vital component of an effective training system. We believe that having a corporate policy with regard to training and challenging behaviour is essential. These policies need to stress that not every situation has a training solution.
Extreme situations make bad training policy
As an organisation we are often presented with extreme scenarios which do not have an obvious training solution. A danger is that these can be used to determine a training syllabus. The most common questions we get asked by staff usually start with the expression "What if". Many organisations need to focus on extreme incidents but, that is different from believing that staff training can eradicate these situations. A training syllabus should focus on high frequency behaviours and on avoiding too many "What if" questions.
Evidenced based training
What should we teach staff? There is simply no point in teaching staff responses to rare/low frequency assaults. There is a limited amount of time that can be devoted to training in any organisation. Our practice is to provide a base of core training in physical intervention skills that can be built upon to deal with more complex situations. Critical to this approach is that the methods are evidence based. Challenging behaviour varies dramatically from service to service and across client populations.
Individualised Physical Interventions
The BILD Code of Practice on Physical Interventions (BILD 2002) advocates strongly that training in Physical Interventions should be on a bespoke (customisable) basis. We try to avoid teaching a large range of physical skills on our basic training courses as getting staff to learn and retain physical methods is not a straightforward process. There are other techniques taught by Studio3 staff on an individualised basis for specific high risk situations. These would be part of a reactive plan.
Poor skill retention
The evidence is fairly clear that staff retention of physical interventions is poor, especially on standardised training courses that teach too many physical techniques. Skill decay of physical interventions starts almost immediately after training has ceased and the participant walks out of the room. The Studio3 view is that "less is more", that is there is a better chance of skills retention the fewer techniques are taught on standardised training courses.
Applying physical interventions training to "real world" settings
It is our policy to teach the fewest intrusive intervention methods on basic training courses. We are very aware that physical interventions are often applied in highly aroused situations. Therefore, we actively promote the use of role play methods that evoke fear responses to situations in a safe and controlled manner. In our view, this is the only effective way to generalise these skills to real world settings.
Increasing carer confidence
Training can increase staff confidence in managing challenging situations (McDonnell et al 2008; Allen & Tynan 2000. We believe that staff who are confident in managing "high risk" situations, are more likely to create meaningful opportunities for people. Confident staff are also less likely to use physical interventions. We also believe that defusing high risk situations requires confident staff. Correspondingly, staff who are less confident are usually more fearful and likely to be less effective and safe in managing crises.
Restricting physical interventions
Studio3 is unusual as an organisation as we try to 'discourage' an A la carte approach to PI training. This can create some concerns among a minority of staff who do not like the feeling of being restricted about what they can do in crisis situations. It is understandable that people wish to have solutions for every possible situation; it is also highly impractical and difficult to monitor.
Avoiding teaching high risk Physical Interventions
It is our view that some physical procedures do have an enhanced risk and we believe that we have a duty of care to restrict their usage. There is a growing consensus in the field that we are heading towards restrictions of methods such as prone (face down) restraint holds (McDonnell, 2007). There are heated debates about the safety of these methods (Paterson, 2007; Leadbetter, 2007). We believe there is a real difference between training general responses and the one-off crisis situations that people often face. Repeated use of high risk interventions is in our view an unacceptable practice.
Making Physical Interventions a genuine last resort.
The last resort can often become the first option in many services. Reducing the use of physical interventions in human services requires staff to try all other options first. Keep physical interventions at the bottom of the "tool box".
Organisations require "top down" as well as "bottom up" pressure to reduce physical interventions. A culture of restrictive practices reduction can be a powerful tool. A key element in this approach is good positive leadership. It is our experience that care managers who explicitly communicate clear person-centred values can have a positive effect.
Active monitoring of restrictive practices
Organisations should be clear about what should be recorded. Any restriction of an individual"s movement or choice of movement should be recorded as a restraint. Some services which claim to be "restraint free", for example, do not include escort procedures or seclusion.
Restrictive practices reduction plans
The reduction of restrictive practices in services is a paramount goal. Therefore individuals who regularly are exposed to restrictive practices should have an agreed
reduction plan in place. Whilst we accept that this is difficult to achieve in some extreme situations in our experience it is never impossible.
Andrew McDonnell, PhD,