The use of physical restraint in services supporting individuals with intellectual disabilities (ID) has received much press over recent years. Concerns around the appropriate use and the rights of the people with intellectual disabilities being supported have been considered by many professionals.

Whilst many challenging behavior management programmes have geared their ethos towards managing behaviour positively and proactively to reduce challenging incidents, the use of physical restraints in these situations are still widely reported, even across different countries in the world.

For example, a Swedish study (Lundström, Antonsson, Karlsson, & Graneheim, 2011) found that 17.8% of people with ID living in group homes had been subjected to physical restraint over the previous week (Lundström et al., 2011).

A British study (Emerson et al., 2000) reported that 53% of 500 adults with ID receiving various forms of residential support had engaged in at least one form of challenging behavior (CB) in the preceding month, and of those who had been involved in a significant episode of CB in that period, 44% had experienced physical restraint (on at least one occasion).

Specifically, in the paper being reviewed here, Sondenaa, Dragsten, and Whittington (2015) were interested in the use of physical restraint with individuals who have an intellectual disability in Norway.

In 1999, Norway passed the Norwegian Social Service Act which reflected a change in legislation regarding  the way in which restraint must be used. The aim was to reduce and restrict the use of restraint. This legislation stated that any planned physical intervention must be documented in a person’s care plan and only be performed when nursing staff were present, as well as being thoroughly reported through legal channels.

Paradoxically, since this act was passed in Norway, the use of physical restraint has actually increased, indicating a reliance on these measures as opposed to more proactive behavior management techniques. The authors of this paper sought to examine why this was.

Method

Participants

• 196 participants:
• 178 of these were care workers in homes were physical restraint was approved for use
• 17 were county governors with responsibility for inspecting the use of all physical restraint decisions.

Procedure

Each participant completed a self- guided questionnaire which consisted questions to assess  the following information-

• Possible explanations for the increased number of people with ID subjected to physical restraint
• Possible future developments in these rates
• Views on the consequences of the new policy for quality of care

Participants responded using a Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree) and there was space for individuals comments in each section.

Two further items had an open-ended response format. The first asked how changes in care and treatment had been implemented as a result of the new policy; and the second was about other possible explanations for the observed increase in physical restraint use.

Results

The study grouped respondents into three groups:

• County Govenors
• Nurses
• Assistant Nurses

The nursing staff expressed confidence in their knowledge of the new law (n =170, 95.5%), but also felt that they had not seen any changes in the care for people with ID since the new legislation had passed (n= 99, 55.6%). Additionally they felt that many uses of physical restraint had gone unreported (n=67, 37.6%).

County Governors felt that the increase was due to an increase in legal awareness and a change in attitude, plus previous under- reporting of incidents.

Comparison between groups of respondents found that registered nurses did not always have as much experience as their assistant nurse colleagues.

There was little expectation that the use of physical restraint would decline over coming years

Placing restrictions on the use of physical restraint was more likely to be seen as positive and had created better working conditions, increased management involvement and stronger professional involvement.

Discussion

Overall, the increase in the use of physical restraint within this study could be attributed to a change in attitude, increase in knowledge and better reporting of incidents. We can draw some main conclusions from the findings:

• The increase in reported use of physical restraints was attributed by all staff groups to an increase in knowledge around safe practice and a change in attitude.

• The paper highlights the need for qualified and experienced staff to work within the care setting. In this paper, comprehensive training of staff was attributed to more precise and accurate recording of incidents.

• In cases where staff had felt that there had been no shift in practice since the act came into place, the authors felt this could be due to underqualified but experienced staff being unable to change their long term working patterns

• Conclusions drawn from this study could be questioned due to the small sample size, restricted to just one country. We may not be able to generalize these findings to other countries.

Strengths and Limitations

• The researchers collected questionnaire data from different professional roles within the care setting
• The questionnaire used to collect information from participants used both quantitative and qualitative data, providing a richness in the information gathered
• The researchers analysed the findings thoroughly using both within participant and between group comparisons of responses. This helped the findings to address a number of themes as to why the increase of physical restraint may have increased
• The sample size is small and therefore the findings may not be generalised to all care workers who may use physical restraint across the whole of Norway
• The findings from this study are specific to Norway and as such we are not able to generalise them to other populations and countries

Summary

In summary, some interesting themes in learning disability care emerge from these findings. In particular it would seem that the experience and knowledge of direct care staff is key in implementing safe practice in care settings, as well as the opportunity to access training in order to instill positive attitudes in staff.

The previous under-reporting of incidences where physical restraint has been used is acknowledged by staff within this research sample. In terms of practice implications, it would seem that supporting teams to access training, as well as to rigorously report the use of physical restraint, creates a more open culture within care settings. It seems that whilst the use of physical restraint had increased in Norway, that this may actually be due to safer staff practice.

Overall, this may create safer and more respectful care for individuals with learning disabilities. However, it begs to consider what staff practice around using restraint techniques was like before their legislation changed if many incidences were not reported!

Lastly, we must also remember the findings here were very specific to the sample and country used, and therefore we cannot generalise these findings to elsewhere in the world. I also feel that more research would be valuable into the behaviour management techniques used by staff to reduce the use of physical restraint in the first place. Whilst the increased number of incidences may be due to safe practices, it also leaves the question open as to whether staff are using proactive techniques in avoiding restraint procedures in the first place.

Links

Primary paper

Practitioner Explanations for the Increasing Use of Restraint Measures in the Care of People with Intellectual Disabilities in Norway,  Søndenaa, E., Dragsten,F., and Whittington, R.. (2015), Journal of Policy and Practice in Intellectual Disabilities, Volume 12 (1), pp. 58-63 [abstract]

Other references

Emerson, E., Robertson, J., Gregory, N., Hatton, C., Kessissoglou, S., Hallam, A., & Hillery, J. (2000). Treatment and management of
challenging behaviours in residential settings. Journal of Applied Research in Intellectual Disabilities, 13, 197–215.

Lundström, M. O., Antonsson, H., Karlsson, S., & Graneheim, U. H. (2011). Use of physical restraints with people with intellectual dis-
abilities living in Sweden’s group homes. Journal of Policy and Practice in Intellectual Disabilities, 8, 36–41.