Wednesday 4 September 2013

Restraints – The dark side of care?

"They kick, punch and bite us, what do you expect us to do?" The words of a social care worker caring for people in a residential dementia unit, explaining why they sometimes have to physically restrain their residents or request prescriptions for antipsychotics.

The use of restraints is only legal in England and Wales if it is covered by a Deprivation of Liberty Safeguards (DoLS) order which, according to recent figures released by the Health and Social Care Information Centre, have increased year-on-year since their introduction in 2009. 11,887 applications were made in 2012/13, of which 54 per cent related to people living with dementia, but as a society how do we feel about restraining people with dementia, even when it is done legally?

Restraints can involve using bedrails to keep someone in their bed, straps to tie them to a fixed object, seatbelts on chairs or locking them in a room. I’ve seen care home residents belted into wheelchairs to stop them from moving about – although one gentleman proved sufficiently strong to get to his feet and move around with the chair attached. I’ve also seen residents who have been strapped into wheelchairs injure themsevles trying to get out of the chair, with chairs ending up on top of them or arms and legs getting entangled with metal.

As far as bedrails are concerned, I saw extremely high ones used on a man in a hospital bed to try and prevent him moving around the ward, but this was entirely inappropriate since he managed to climb over them on numerous occasions and eventually hurt himself as a result. Very low-level bedrails were used on my dad’s bed in the last couple of years of his dementia, but my written consent was obtained before they were used and their purpose wasn’t as a restraint, but purely as a safety measure to ensure he couldn’t roll out of bed onto the floor (he was already immobile so wasn’t being prevented from getting out of bed by them, merely from falling during his sleep).

The use of antipsychotics was of course once commonplace in dementia care, as I wrote about here, with my dad enduring a period on this type of 'chemical cosh' medication before we managed to get it stopped. I am still regularly contacted by families who are having to cope with the trials and tribulations of having loved ones with dementia on antipsychotics, despite such prescriptions now being seen very much as an absolute last resort for only the most severe dementia symptoms when all other interventions have failed.

So how do you cope as a care worker if you are going into work every day and being kicked, punched and bitten? The answer is you potentially don’t, but more often than not that is due to a failing in the system, rather than something the person with dementia or indeed the person caring for them can control. If anything, those two individuals are the biggest losers in a system that too often resorts to factory farming our older people. A lack of funding for care has led to cutbacks in staffing levels and specialised training in many organisations, and the result could be described as a return to the dark-ages of care provision.

What is perhaps most alarming about the situation around DoLS applications isn’t the number of applications being made or indeed the number being approved, it is the persistent fear of how many restraining practices are being used illegally. Behind closed doors many ‘professionals’ are looking for a quick fix for ‘challenging behaviour’ that will take up minimum staff time but provide maximum effect in terms of containing someone who they see as a problem. For them, a DoLS order isn’t necessarily a priority, particularly as they would need to show that the restraint measure being proposed is appropriate, in the person’s best interests and is the least restrictive possible.

In my mind, depriving someone of their liberty should only be done in the most extreme cases, when all other avenues of care and support have been exhausted and the person with dementia is a direct danger to themselves or others around them. To avoid the need for restraining measures, organisations may need to implement institutional changes in the way care is provided in order to alter staff behaviour resulting from a cultural lack of understanding of dementia, with someone leading those changes who believes that there is another way to approach dementia care.

If staff have never been trained in how to cope with someone experiencing severe dementia symptoms, like aggression, confusion, walking, problems with orientation or issues with sleeping, they are likely to feel out of their depth and looking to resort to restraining methods to protect themselves and those around them. It’s a natural instinct, but it is an instinct that never needs to be seen if an organisation is capable of responding to the needs of individuals with appropriate staffing levels and by embedding a culture of person-centred care throughout their organisation.

I’m not saying that dementia is an easy disease to manage, but however hard it is to look after someone experiencing it, it is far harder for them to actually be living that experience or indeed handling the consequences of the actions of those who are charged with caring for them. Sadly most organisations are so financially squeezed that they are operating on budgets that don’t allow for either specialised training or one-to-one care provision, therefore restraints, be they physical or pharmacological, are a cheap, simple solution.

In situations where that is true, I feel a deep and profound sense of shame that we cannot respond in any other way, and even when organisations have a DoLS application approved and are acting entirely within the law, I struggle to comprehend how we cannot enshrine in law care practices that could avoid the need for restraint altogether. Idealistic maybe, but consider this. Dementia may remove someone’s ability to be proportionate in their response, but those not living with dementia cannot claim the same. In my mind we must always be proportionate in our response.

Until next time...
Beth x

You can follow me on Twitter: @bethyb1886


  1. Tough call Beth-the home where i work has two interior units that are entered by use of a key-pad. I'm normally in the ground floor unit where i have sole care of 7 ladies with severe dementia.
    I too am attacked daily but more worrying is that one lady in particular attacks the other ladies within the unit. It's really hard to be giving personal care to one lady and keep an eye on the others-they are all mobile and constantly wandering in and out of each others rooms and getting into all sorts of scrapes. I seem to spend as much time filling in safe-guarding forms as carework.
    There are no restraints used but i'm finding it particularly hard at the moment as one of the activities that was used to help the ladies focus has been taken away (the telly.) The reason being that one member of staff was found watching something that was deemed unsuitable (it was to be fair-Jeremy Kyle :/)
    The ladies are suffering through it being gone though-it really helped when there was aggression that needed diffusing.
    I don't agree with restraints-but i do wish my management would work with me on ways on making the unit i'm in charge of safer for me and the ladies. An extra member of staff would help enormously :(
    Love the blog xx

    1. Thank you for your comments. Really interesting to hear about your experiences.

      Yours is a classic example of what I've written about - lack of staff, lack of time, lack of resources. With more staff members you could provide more personalised, supervised care, and with more resources you would be able to occupy your ladies, thus helping to diffuse difficult situations.

      I have to say I find it appalling that the actions of a member of staff have resulted in the TV being taken away. I'm personally not a fan of TV's being on constantly in care homes, but I think they are a brilliant resource for playing meaningful DVD's of films/musicals/old TV programmes etc to residents - indeed whatever the residents enjoy watching. This type of entertainment would help to provide focus within the day. Alongside opportunities to do practical tasks this would help to keep residents occupied, but of course it does need high-staff numbers to facilitate. I hope you do at least have a stereo and CD's of resident's favourite music that you can play for a sing-along.

      I can only imagine your frustrations. The key to delivering effective, person-centred care has always been a high level of well-trained staff, resources and support. Without that, even the best staff members cannot provide the care that they would want to.