Physical Interventions: Managing Risks by Mastering Data

The risks posed by rugby are in the headlines at present. A collective of 70 academics and health practitioners have recently called for a ban on full-contact rugby in schools to protect students from the ‘potentially devastating consequences’ of the injures that can arise from participation. But what does this tell us about managing the risks arising from the use of physical interventions?

At the highest level this debate highlights a basic truth; that the transfer of energy from one person to another comes with significant risks. The litany of injuries arising from football, rugby, martial arts and boxing all stand testament to this fact. By definition ‘physical intervention’, which has been defined by Harris et al (2008) as ‘any method of responding to challenging behaviour which involves some degree of direct physical force to limit or restrict movement or mobility’, involves physical force being applied against active resistance. It is in this ‘danger zone’ that key tissues and vital anatomical structures come under damaging stress.

In the second instance, when such interventions are sanctioned or approved by an organisation contracted to provide care and support, a duty of care will exist. This means the recipient can rightly expect protection from harm. But before you can answer the question as to ‘how’ you can protect someone from potential harm the question you need to ask and answer is ‘what is the nature of the harm and exactly ‘where’ does it arise’?

In answer to this question the aforementioned rugby safety advocates can point to their own unique data. In a recent BMJ article, Doctors from the Department of Trauma and Orthopaedics at Tallaght Hospital in Dublin, described three cases where young players had been seriously injured during rugby tackles. They had experienced complicated hip fractures as well as dislocations that were consistent with the body position and resultant forces arising from two-man tackles, where one tackler hits low and the other hits high.

Further data analysis identified another risk factor, namely the size and strength disparities between players increased risk. In the BMJ article it stated that, ‘Many schools and juvenile rugby clubs have adopted a more professional attitude towards the game, with a significant emphasis being placed on weight training and physical size.’ The net result being that bigger, stronger players are bringing excessive force to bear in tackles. As a result of this what must be considered also are the implications of the impact of such force on an immature musculoskeletal system. During adolescence muscles and bones, which afford the player protection against injury, are maturing at different rates. Any differences between players are likely to be magnified through the physical prism of tackles and rucks, when physically bigger players come into contact with smaller, weaker counterparts.

So where does this leave us with regard to the risks arising from physical intervention?
What we know is that ‘restrictive practices’ can cause injury. It has been reported that 1 in 3 episodes of physical intervention are estimated to result in some form of minor injury to the person with a disability (Tilli and Spreat, 2009). We also know that in some instances restraints have resulted in the death of supported persons within the social care setting (Paterson et al, 2003) The Case of Zoe Fairley is sadly representative of the dangers of physical intervention.  She died after she was “pinned down” by four social workers at Howe Hill Hostel in York when she was restrained following a behavioural outburst. Ms Fairley was an adult with learning disabilities.

On that basis it’s accurate to say that danger exists.

We also know that the outcry arising from untimely and unnecessary deaths has resulted in a drive to eliminate high risk practices such as prone restraint (Dept. of Health, 2014) This in turn resulted in the development of new guidelines: ‘Positive and Proactive care: Reducing the need for restrictive interventions’ (Dept. of Health, 2014a) within which, it states that the Care Quality Commission (CQC) will monitor and inspect organisational progress against restrictive intervention reduction programmes.

The Dept. of Health (2014a) state that ‘Accurate internal data must be gathered, aggregated and published by providers including progress against restrictive intervention reduction programmes and details of training and development in annual quality accounts or equivalent’ .

According to Hollins (2010) however, the focus on prone restraint has led to a narrow understanding and focus on managing the risks arising from physical intervention. To fully discharge their ‘duty of care’ and comply with the ‘Positive and Proactive’ guidelines organisations need to consider the totality of the risks, including soft tissue and skeletal injuries, as well as how they relate to the specific individual.

In short what is required is good, local data collection and analysis, which can then be used to inform bespoke local practice. The good news for those contracted to look after ‘supported persons’ is the solution to this problem is soon to be launched. A York based company called Securicare and a Cambridge technology company called Sleuth have developed a health and social care behaviour management support programme.

SecuriCare provide specialist health and Safety training designed to help staff manage work related violence, disruptive behaviour and deal with challenging behaviour across through the health and social care sector. Training includes lone working/personal safety, preventing and managing challenging behaviour, physical intervention and restraint risk reduction training. Training and courses are Nationally Accredited by Pearson, ICM, and BTEC. They also offer Qualified Teacher/Trainer Awards at Level 3.  SecuriCare also provide support with risk assessment and the development of safe working practice and staff guidance.

electronic behaviour monitoringSleuth is an electronic behaviour tracking system that records and analyses behaviour. Developed by experts at the School Software Company it provides an effective, consistent, whole service system for managing challenging behaviour, and tracking/analysing the use of restrictive practices including physical interventions. The system has long been the premier behaviour tracking system used in the education sector and has been successful in contributing to improvements in behaviour management in hundreds of UK schools.

Between them Securicare and Sleuth can provide a flexible, organisation wide data collection system, along with the capacity to facilitate behavioural analysis as well as the design and delivered of focused local training solutions. Their collaboration is one that is going to protect vulnerable service users, and even save lives.

By Lee Hollins BSc (Hons), PGCert Health Research

References

Department of Health (2014) Press release: New drive to end deliberate face-down restraint. https://www.gov.uk/government/news/new-drive-to-end-deliberate-face-down-restraint

Department of Health (2014a) Positive and Proactive Care: reducing the need for restrictive interventions, Social Care, Local Government and Care Partnership Directorate

Harris, J. (1996) Physical restraint procedures for managing challenging behaviours presented by mentally retarded adults and children. Research in Developmental Disabilities, 17, 2, 99-134.

Hollins, L. (2010). Managing the risks of physical intervention: developing a more inclusive approach, Journal of Psychiatric and Mental Health Nursing, 17: 369-376.

Morrissey, D., Good, D & Leonard, M. (2016) Acetabular fractures in skeletally immature rugby players. BMJ Case Reports Published 7 March 2016; doi:10.1136/bcr-2015-211637

Paterson et al. (2003). Deaths associated with restraint use in health and social care in the UK. The results of a preliminary survey, Journal of Psychiatric and Mental Health Nursing, 10: 3-15.

Tilli & Spreat. (2009). Restraint safety in a residential setting for persons with intellectual disabilities, Behavioral Interventions, 24: 127-136.


About Sandra Nelson