To think that face down restraint is never acceptable

(92 Posts)
ReallyTired Wed 19-Jun-13 23:08:23

I was shocked to see this on the BBC website

Certainly restraint is sometimes necessary in mental hospitals or schools, but it needs to be done with as much love as possible. Restraint should be reserved for situations where the alternative is far worse. (Ie. force feeding an anorexic child close to death who is far to ill to make a decision about eating can be a loving act.)

There are lots of ways of doing restraint that are far safer than face down and preserve the dignity of the person. Restraint should never be done for sheer convience. When restraint is done inappriopiately then the staff should be punished.

Idrinksquash Wed 19-Jun-13 23:16:34

Face down restraint isn't used willy nilly you know.

As an RMN I can assure you there are a lot more appropriate uses for restraint than forcefeeding a person suffering with anorexia nervosa. I was once shoved into a wall and punched in the stomach by a service user at 28 weeks pregnant. C

Idrinksquash Wed 19-Jun-13 23:19:31


It was completely out of the blue. No warning signs, no 'situation' I could have dissolved. Really pisses me off when people jump on the "nurses are horrible to patients" bandwagon.

complexnumber Wed 19-Jun-13 23:20:50

"Certainly restraint is sometimes necessary in mental hospitals or schools, but it needs to be done with as much love as possible."

I don't thing 'love' needs to come into it.

When one person becomes a danger to him/herself, yourself and to others in your care, you need to respond accordingly if it is your job to supervise.

Idrinksquash Wed 19-Jun-13 23:21:00

Oh and FYI, you can't force someone to eat. Thats against their human rights.

Dahlen Wed 19-Jun-13 23:21:49

Hmm. On the face of it of course YANBU. But that's the trouble. Things are rarely as they seem on the face of it.

Public servants on the front line are just people. Like you and me. They can be trained in techniques and assessed for suitability in temperament, but when it all goes wrong and it becomes a physical battle of wills, they have a right to protect themselves and end the physical conflict as quickly as possible with as little physical damage as possible. Sometimes that it is going to mean face-down restraint because there is no time or opportunity to work out how to do it any other way. That doesn't mean they shouldn't be held accountable for extreme use of force of course.

complexnumber Wed 19-Jun-13 23:28:04

I'd be interested to learn of the "lots of ways of doing restraint " when you are being threatened with a kitchen knife.

YouTheCat Wed 19-Jun-13 23:31:00

You do realise that that kind of restraint will be a last resort and will only be done by those qualified to do it, OP?

KatoPotato Wed 19-Jun-13 23:31:31

I'm an MVA trainer for secure sites, as a policy we never train face down restraints or to prone. We teach staff to be aware of legalities and their own rights and of the rules of proportionate and reasonable force.

ReallyTired Wed 19-Jun-13 23:34:51

What situation requires face down restraint? There are far safer and more humane ways of restraint. Surely the aim of physical intervention is not to terrify or to inflict pain. Carers should look to maintain a safe enviroment.

I have no experience of mental hospitals. I have seen physical restraint in a special school situation. I have seen large teenage boys being restrained without being face down. In fact I had training on how to do physical intervention. It is important to choose restaint techniques that maintain dignity and are as safe as possilbe.

KatoPotato Wed 19-Jun-13 23:35:16

If you are being threatened with a weapon then your first response would be to make your escape and try and isolate them. If you were unable to do so then the rules of proportionity and reasonable force would be applicable.

I'm an MVA and restraint trainer and we never teach any prone or face down techniques as the consequences are horrific.

KatoPotato Wed 19-Jun-13 23:35:53

Sorry, thought first post had vanished!

sweetestcup Wed 19-Jun-13 23:36:23

I presume by the term "mental hospitals" you mean acute psychiatric in-patients wards OP? Have you ever worked in one and faced a patient requiring restraint? I am an RMN and I have and I can assure you it was always based on a clinical judgement that it was the only option, such as to maintain their safety, the safety of fellow patients or staff.

I have been restrained in a mental hospital (not face down).

It is traumatic being restrained, very unpleasant and upsetting. I think in some ways it made being IP more stressful, I was very scared of it happening again (and it did).

However, it was done to protect me from killing myself, it was to protect me. I think it was used appropriately.

I have never seen restraint used lightly. I think it must be hard work being a MH nurse. I certainly think that part of training needs to include the patient experience, I would have liked a debrief afterwards.

It is hard to explain how it feels to be restrained, to be held down like a criminal when you are not one.

KatoPotato Wed 19-Jun-13 23:55:22

You're absolutely right fluffy and when a site finds that the need for restraint is high then there are a number of newer alternatives like restraint belts and the like which are highly effective.

MichelleRouxJnr Thu 20-Jun-13 00:07:09

Hello OP
Today I had a coffee table thrown in my direction by a man who was approx 6'3 and 20stone. Not fat - muscley.
I'm 5'6.
As he spat and swore and tried to prise the bookshelf from the wall I was most pleased when 5 health care workers arrived (after I pulled my alarm) to control and restrain him - prone - and reassure him he was safe and talk kindly to him while I drew up and administered some medication.
The medication was administered to his buttock area, which would have been inaccessible had he been supine.
When I left the secure mental health unit I work in, he was sleeping and the other 12 patients and the staff were safe.
In a few weeks he will be mortified by his behaviour and thank us all for keeping him safe.
As he has been the last 3 times he has had a distressing violent psychotic episode.
'Love' ???? Get real - we are professionals who treat people with respect and try to uphold their dignity while keeping ourselves and others safe.

Goldmandra Thu 20-Jun-13 00:09:49

I don't know about restraint used in psychiatric wards but I am concerned about how restraint is used in schools.

I have two DDs with AS who attend Autism-specific provision. My own DDs have never been restrained in school, although there is a chance that DD2 may need this at some point to prevent her from running into danger.

I am aware though that restraint is used in that provision for reasons I don't feel are justified. They use physical restraint to force pupils to attend lessons when they don't want to go and as a just-in-case measure when a child appears upset.

I have seen one child being taught while being restrained. I can't imagine what they thought he might be learning.

When I have raised concerns I have learned that restraint for these reasons is considered acceptable in schools.

I've written to tell them that restraint must never be used on my DDs unless they are putting themselves or someone else in danger.

I have also been told that there is no legal requirement on the staff to inform parents when restraint has been used.

YouTheCat Thu 20-Jun-13 00:12:16

Gold, tbh that doesn't sound right at all.

I would not expect a face down restraint to be used in a school setting.

ReallyTired Thu 20-Jun-13 00:12:58

Surely restraint belts are similar to the straight jackets used in victorian times. It would require force to get someone in a straight jacket.

I have never worked on an acute psychiatric in-patients ward. I have worked in a special school where large teens have been restrained for their own protection or other people's protection. I even had training and we told that putting someone in a prone position is dangerous.

The school I worked in tended to restrain children is a sitting postion. Much of physical intervention training is descalating a situation. If someone is face down then it makes communication with them hard. Surely face down restraint makes it harder to descalate a situation. How can you talk to someone if their face is in the carpet?

I have no problems with physical intervention done in the right circumstances. I have issue with face down restraint. Some health trusts have already banbed face down restraint and I feel the rest of the country should follow.

MichelleRouxJnr Thu 20-Jun-13 00:18:17

What's a restraint belt?
Restraint is safely handling a person to a position where they cannot hurt themselves or others and holding them there for the shortest time possible?
I appreciate the difference in children/adolescents and adults but as a forensic practitioner in a secure hospital I can assure you that sometimes a short (minutes) time in a prone restrained position is the only safe option.
Perhaps you ought to amend your title and OP to show you are talking about children.

KatoPotato Thu 20-Jun-13 00:20:33

michelle I teach restraint positions that do allow you to administer medication in the buttocks without the risk of death by prone and corporate manslaughter litigation. If you want deatils for you site please pm me.

Michelle - I appreciate how difficult your work must be, I have not been an IP in a forensic unit although I have been IP in PICU and seen restraint used there.

But, not everyone who is restrained is being violent towards staff or other patients. I am peaceful, but I was not going to let anyone get near my neck to cut off a ligature and I really didn't want to go into seclusion because what I really wanted was to leave the unit and kill myself. And restraint was used to keep me safe from myself.

I guess I am coming from another perspective and I think it needs to be 50/50 when looking at the impact of its use - on staff and on patients.

I am mortified that I had to be restrained, I was psychotic and not thinking straight, it was the right thing to do. I was made aware that I would be restrained to be given medication if I did not comply. The whole thing is frightening and scary - just as much for patients as for staff.

I am scared of being re-admitted to hospital and I think it is unlikely I would ever go in informally because I would be scared of being sectioned while IP and restrained to take medication, and scared of being restrained to stop me doing things. Hard to explain.

The day after I was first restrained I had a very very vivid flashback dream about being raped, the first I had had in years. Very difficult and upsetting and led to a really bad few weeks for me. Restraint has a huge impact and it is important for all staff to remember that.

If face down restraint can be banned in some trusts it can surely be banned everywhere?

IneedAsockamnesty Thu 20-Jun-13 00:59:44

Gold,that is not correct. If the situation is as you describe then its a misuse of positive handling.

It would be worth bringing it to the attention of ofstead and the LA

martha2013 Thu 20-Jun-13 03:54:17

I have been restrained, face down, as an inpatient a couple of times. I am horrified to think of this now, not because of the discomfort or humiliation but because of how appalling my behaviour is when I'm unwell. I'm glad the nurses had an established method of dealing with the situation that kept everyone safe. I would certainly agree, however unpleasant, that it has its place.

McGeeDiNozzo Thu 20-Jun-13 05:14:13

'Oh and FYI, you can't force someone to eat. Thats against their human rights.'

Not necessarily. Sometimes it is and sometimes it isn't.

McGeeDiNozzo Thu 20-Jun-13 05:19:04

A bit more detail: if you Google, there's a PDF document about the right to refuse medical treatment and how the ECHR accounts for that, and it goes into some detail about force-feeding anorexics. The author comes out quite strongly on the side that it SHOULD be against someone's human rights if they're forced to have medical treatment, but says that there's no explicit provision in the ECHR. I haven't linked to it because I'm not sure about the policy on such things, but it's easy enough to find.

hellhasnofurylikeahungrywoman Thu 20-Jun-13 05:22:37

Gold I have worked in a special school and have been trained in de-escalation and positive handling but the county I work would never, ever sanction a child being educated while they were being restrained. All restraints were used for the shortest possible time. It is absolutely wrong to use restraint in that way within a school.

MammaTJ Thu 20-Jun-13 05:49:13

Another AIBU where the OP refuses to read the replies that say YABU!

Read what MichelleRouxJnr has to say OP before replying again I have no problems with physical intervention done in the right circumstances. I have issue with face down restraint. which you said after they had posted. I think that they have given a perfect example of when it is not only acceptable, but absolutely necessary.

Doubtfuldaphne Thu 20-Jun-13 07:17:04

I just wants to share my story.. I was 10 when I developed school phobia. I became terrified and physically ill if I had to go to school after suffering a panic attack during a class and no one knew what was wrong with me. (This was in the early 80s)
A social worker was brought in to just get me to school.
Every morning I was restrained face down. I was really scared. Only now I realise what an absolute bitch this social worker was and it made my problem ten times worse.
That's the only experience I have of face down restraint.

HollyBerryBush Thu 20-Jun-13 07:19:30

Oh and FYI, you can't force someone to eat. Thats against their human rights.

Ian Brady has been arguing that corner for 13 years.

plentyofsoap Thu 20-Jun-13 07:30:54

Put yourself in very violent and dangerous situations before making such judgements really.

I have seen it used on an 16 year old drug induced psychotic patient after de escalation had failed by 3 senior clinicians. He was in the process of attacking a nurse, had her cornered after picking up a huge flat screen telly (not one with a flat back but the big old huge ones) and throwing it around as if it was nothing.

Face down restraint is used as a last resort, the people who do it are trained to use lots of techniques first.

Seriously I only see mentally ill adolescents but sometimes that illness can give you the strength of 10 elephants and as you can't fight back when being attacked but just restrain for the patients and your safety face down restraint is often required and the best thing for safety of the patient and staff.

Can I ask if you just saw the report on TV or actually have any experience of being in a mental health or criminal setting?

Oh and you have to use the mental Heath act to force feed someone (although this means the insertion of an NG tube and not holding someone down and forcing food into their mouth!) it is done as a last resort.

rainbowslollipops Thu 20-Jun-13 07:38:09

I always thought restraint was when you stop a dangerous person from becoming a danger to others in a bad & angry situation. I thought force feeding someone wasn't restraint but welfare of their health.

Doyouthinktheysaurus Thu 20-Jun-13 07:40:08

I have just done my prevention and management of violence update and there has been a huge shift towards supine restraint.

Whereas we used to be taught prone first and foremost, with supine as an alternative based on clinical need, we are now advised to use supine techniques with prone as a last resort, and turning once the patient is on the floor if the patient is prone.

Turn from supine to prone to medicate and straight back.

According to our trainer, prone restraint is now banned in psychiatric units in Wales.

And if staffing numbers were high enough a lot of incidences of where restraint is needed would not happen.

A funding issue again!

MammaTJ Thu 20-Jun-13 07:41:28

Madame, that was the case even as far back as the 80's wrt force feeding.

delboysfileofax Thu 20-Jun-13 07:48:23

What a crock of shit OP. how many people have you restrained? The people/trainers who come up with the restraint system clearly have no idea how it works in reality. It's often taught with lots of staff being available for each limb and the detainee starting at a compliant point. ie already in whatever position is needed for that particular restraint. It's bollocks and it never ever works in reality

But I think for people who do not know anything about management of people refusing to eat the phrase force feeding is inflammatory and gives a different impression of what it is.

CloudsAndTrees Thu 20-Jun-13 07:50:07

This isn't something I know much about, I have no experience and the article linked to in the OP gives little information.

From the POV of a layperson, I think other methods of restraint should be used if possible, but I also think that the priority is to protect staff, other patients, and the patient themselves. If staff are in a situation where they are using face down restraint for a reason, then I don't think it's fair to talk of punishing staff. They put themselves in dangerous situations for the good of other people, and their protection is more important than dignity IMO.

The BBC article identifies a lot of restraint being used, not unnecessary restraint being used. Perhaps the story should be that large numbers of nurses other staff and other patients are subject to violence of a level requiring restraint on a regular basis.

I've seen some pretty horrific attacks while I've been a mh nurse, including a colleague being stabbed multiple times, nearly resulting in their death. Face down restraint is the safest option in a really scary situation - the mechanics of the body mean it's harder to fight.

Bobyan Thu 20-Jun-13 08:03:19

What atthe said.

And as for "Done with as much love possible" you clearly haven't been scared for your life by a violent patient have you OP?

I have a friend who works in a psychiatric unit where the patients are very violent. I'm not sure of the correct terms, sorry, but the patients need to have 5 or 6 people with them at all times if they are moved or anything like that (I'm probably explaining it wrong, sorry if I've offended anyone). He is trained in face down restraint and it is only ever used as a last resort. When you have a 20 stone violent patient who doesn't have the mental capacity to be reasoned with and they are biting and tearing at you, I don't see what other choice people have. It can't be a lot of fun for the people doing the restraining either I wouldn't have thought.

If any form of restraint is used inappropriately then of course it should be dealt with, but I'm sure it isn't just used for the hell of it.

Doyouthinktheysaurus Thu 20-Jun-13 08:08:01

I agree with the switch of emphasis from prone to supine. It is safer for the patient, postural asphyxiation is not a myth, it is a reality. Also I think the patient being face up can benefit verbal de-escalation. If the patient was being so aggressive supine was risking staff injury, I would push for secluding them, not remaining in prone for any period.

Restraint should only ever have a core team of 3 anyway. One on each arm, one on the head. A person on the legs, only if needed. In the prone position with someone on the legs, the pressure on the chest is massively increased. Obviously the more pmva trained staff available the better, but only for wider management and swapping team members.

yaimee Thu 20-Jun-13 08:24:04

I think this thread shows a fairly shocking lack of consistency amongst those who work in settings where restraint is used.
There should be standardised training, shouldn't there?
It certainly seems that at the moment the training is open to interpretation by both the trainers and those being trained and that not everyone is using the same methods of restraint or using restraint correctly.

Goal Thu 20-Jun-13 08:32:09

I would guess that it because those posting work in different types of settings

yaimee Thu 20-Jun-13 08:35:06

That shouldn't mean they have different attitudes to use of restraint.

MrsWolowitz Thu 20-Jun-13 08:40:50

YABU and naive.

Doyouthinktheysaurus Thu 20-Jun-13 08:46:53

I agree with yaimee, there should be more consistency.

The trainers who train us wrokign in acute care also train those working in forensic and secure services, with exactly the same techniques!

shewhowines Thu 20-Jun-13 08:54:34

As someone who is completely ignorant on this, I would view it this way.

1. The safety of the carer always comes first, and trumps the welfare of the person needing restraining.
2. The least invasive restraint technique should be employed.

The trouble is, there is a very large grey area, when someone is feeling threatened and in danger.

I would defend the right of the carer to go in too hard, rather than put themselves in danger by worrying about consequences. Obviously if there is a pattern of always being far too heavy handed, then these people are not suited to the job and/or need greater training.

sweetestcup Thu 20-Jun-13 09:03:39

So you have never worked in acute psychiatric inpatient setting OP and faced the situations I used to... and yet you think you can judge about the use of restraint there and waffle on about love?!! You really don't have a clue....

MammaTJ Thu 20-Jun-13 09:06:12

*1. The safety of the carer always comes first, and trumps the welfare of the person needing restraining.
2. The least invasive restraint technique should be employed.*

Yes, that. The thing is, what the OP is talking about often is the least invasive technique possible. My experience of working in a psychiatric hospital really is a long time ago, but that was the case even then.

bluestar2 Thu 20-Jun-13 09:15:52

Yabvu. Clearly you have never been in position where you have had to deal with violent people.

Yaimee every situation is different and requires a different response based on environmental and physical aspects. Every response should be tailored to achieving what needs to be achieved using as little force as possible. There can he no one set of rules to follow in a stringent order but rather a box of techniques or tools which the trained personnel can pick from the appropriate one.

mignonette Thu 20-Jun-13 09:30:22

Sometimes restraint techniques have to be used after an unexpected outburst that places all those in the vicinity at risk.

But in my experience as a RMN on various PICUs, FIPMHU's over the last 20 years, restraint is used because staff have failed to act upon earlier and obvious signs of a deterioration in mood and escalation of risk. The risk assessment process is only useful if staff maintain awareness of the 'mood temperature' of a unit and take pro active action.

There are many reasons why this may happen- low staff levels, poor skills, poor management and ward/unit culture. But having to use restraint should be seen as a 'failure' of sorts and actions taken to identify why it happened and whether an earlier intervention would have prevented it.

ReallyTired - I don't think you can judge until you work in these roles. As some one up thread said, sometimes it can be an 'out of the blue' attack, can put others in danger and actually the only suitable response.

Having a brother who is a policeman, a friend who is a prison officer, and another friend a nurse on an MH ward, all of whom come across people with MH issues every day, and equally violence every day, I would most certainly not (a) presume to think I know what it's like, or know better (b) ask them to put their safety over and above the dignity of the individual involved.

I can only imagine the sheer second you would have in these situations to decide what to to do. And if face down restraint would remove most of the risk before any serious violence was done, then I can only support that.

ReallyTired Thu 20-Jun-13 17:42:46

I had physical intervention training in my last job. It is perfectly possible for to physically restrain a large and strong adult without putting them face down.

When a restraint goes wrong it can result in death or injury of the patient.
This mind article shows that trust vary a lot on restraint methods used.

I find it shocking that half of face down restraints happened in two NHS trusts. Face down restraint is more dangerous than other methods of restraint.

I think that people on this board forget that pychiartic impatients are not criminals and they are often very ill. It does not need a mental health qualification to say that these people deserve to be cared for. Certainly there are times when restraint is needed but still important to avoid pain and lack of dignity.

"I can only imagine the sheer second you would have in these situations to decide what to to do. And if face down restraint would remove most of the risk before any serious violence was done, then I can only support that."

That is where proper physical intervention training comes in. Lots of organisations can restrain adults in safe ways that does not involve face down restraint.

Alisvolatpropiis Thu 20-Jun-13 17:50:34

Oh and FYI you can't force somebody to eat it's against their human rights

Erm...yes you can.

Idrinksquash Thu 20-Jun-13 18:07:01

Ok. So you "can" forcefeed people. Just not in my trust, or the private inpatient unit I used to work in.

now lets all get back to the OP's point instead of repetitive posts correcting me. I made a mistake, it only needed correcting once. Vipers, the lot of ya

Alisvolatpropiis Thu 20-Jun-13 18:14:44

Sorry Idrink smile

Re op's point - I don't think any professional who works in a field in which physical restraint can be a part should do anything out of "love". Nor out of hate. Way too strong an emotion.

They do it because they are professionals and it is their job to keep that person and others safe from harm. As others who have worked in physiatrist ward said, sometimes prone restraint is the only way.

Alisvolatpropiis Thu 20-Jun-13 18:15:16

*physchiatric even

Alisvolatpropiis Thu 20-Jun-13 18:15:48

Ohh FFS! <gives up>

BinksToEnlightenment Thu 20-Jun-13 18:22:45

I've seen it used frequently and inappropriately, and experienced it personally. It's not a nice thing and denying that there is any chance a culture of inappropriate restraint could develop is not helpful. The place I have seen it used would never have been closed down if no one had considered the possibility it was happening.

Jollyb Thu 20-Jun-13 18:38:19

Really tired - you've had the training but have you ever had to use it in real life?

Tomorrowslookingfine Thu 20-Jun-13 18:52:53

I too question how often OP has had to use restraint?

Onesleeptillwembley Thu 20-Jun-13 18:54:14

Ok, OP, you have an extremely large, strong and violent person who is HIV positive attacking someone. You have to stop it. The attacker has previously bitten off part of a colleagues' face. Has tried to bit on many previous occasions. Also bites own lip and spits. What exactly do you do, within strict legal constraints?
I think you need to grow up and realise that you shouldn't really be making such ridiculous black and white judgements about which you admit you have no experience. Or do you just want to make some jobs so dangerous nobody would do them?

Blissx Thu 20-Jun-13 19:15:12

Just wanted to say how amazing some of you are to do the jobs that you do. Just hijacking the thread to say how much I admire those on this thread who work in the environments described.

PenelopePipPop Thu 20-Jun-13 19:53:24

I want to say how much I admire Fluffydressingdown who has experienced restraint herself as an inpatient and come on to this thread to say that it was necessary, that it was acutely distressing and undignified and that staff need to be aware of both the short and long-term effects of using restraint when they assess how to intervene in a situation. In other words that she does not blame the people who intervened in her care in the way they did but it would be good if we thought more deeply about the patient's experience of restraint, not just as dangerous or frightening but also as triggering flashbacks and making them mistrustful of services in the long-term.

You are awesome Fluffy.

ReallyTired - thank you for your posts on this thread, I feel very sad reading some of these comments tbh.

Actually I consider my dignity, my welfare, my safety to be as important as those looking after me. When I was unwell I was incredibly vulnerable, I was so unwell that I was, at times, not safe enough to be alone to pee. I could not leave the building, I simply did not have the capacity to make my decisions. At that time I needed people to make the safest decisions for me and some of them did include restraint. But I am not a criminal, I did nothing illegal, I hurt noone other than myself. I mattered just as much as those staff.

I feel like if you read this you will read that those in psychiatric units are violent and angry and aggressive. Mostly people are exhausted and scared. And I would agree with the poster that said that in many cases restraint is the end of an series of behaviours that could be prevented. Many times when I was restrained I had clearly indicated I would not be able to keep myself safe, sometimes they changed my obs or offered support, but at times I was literally left to hang myself. I think personal responsibility is important but it is and was very frustrating to have people stopping me from doing something that I said I would do.

Having your choices, your control taken away from you is horrendous. Can you imagine having the choice of taking medication 'voluntarily' that you don't think you need or want and that has very significant long term side effects or being pinned down and injected with it. These were decisions I faced weekly - at a time when I found even deciding what to watch on TV to be hard. Psychologically it is very very difficult to manage.

Restraint is needed to keep people safe but like I say it needs to be remembered how much an impact it has in the longer term.

YoniRanger Thu 20-Jun-13 20:24:34

Restraint of any kind should be the absolute last resort. Prone restraint should be avoided because its vile for the person, dangerous and in a situation where medication is not involved it is really unlikely to calm the situation.

That said if the alternative is more likely to cause significant harm then you do what needs to be done.

PenelopePipPop Thu 20-Jun-13 20:34:53

Yep and there is a huge body of empirical evidence that would support you. Depending on the type of setting a combination of improved staff training, the use of de-escalation techniques specific to calming agitated patients in emergency care, and changes in policy and leadership can all dramatically reduce the use of seclusion and restraint. Happy to provide cites for all that - this is my academic specialism and yes I have worked with loads of people suffering severe psychotic breakdowns.

There are Mental Health Trusts in England and Wales which have shown this kind of commitment to improving the safety of their staff and patients, and there are others which have not. That is the point of the news story which ReallyTired linked to.

I can understand why people who have carried out facedown restraint probably feel a bit shit about it. To be told it might not even have been a justified practice, and that alternative techniques might have been safer and better for everyone involved (and that in the neighbouring county that might be what happened) is a kick in the teeth. That might be why you got such a hostile reaction on this thread. It is still a bit sad to see mental health professionals responding so defensively and patronisingly when a service user takes the time to articulate why restraint is unpleasant and how it can be avoided.

mignonette Thu 20-Jun-13 21:56:20

I was not defensive Penelope. I am an RMN and my earlier post made a point very similar to yours- that most restraint can be avoided; that it should be a last resort; that de escalatiom techniques are often very poor or the will to use them is not there and that there are a myriad of reasons as to why a culture of using restraint develops within a trust/workplace.

I now work as a senior CPN in crisis management because I was no longer prepared to work in in patient services in my trust, one which uses restraint far too freely and recklessly in my view. And I am a thorn in the side of senior managers in my attempts to question every incidence of it being used if and when any of the clients on my case load have to be admitted.

(I have worked in a very well known Forensic hospital giving me ample experience of prone and supine C+R and calling it 'care and responsibility' instead of 'control and restrain' doesn't make it any more pleasant to perform or be on the receiving end of)

Penelope I just read your kind words about me, thanks smile

Migonette - it is nice to see someone working in front line MH questioning things, I think this is the key, not just about banning prone restraint but questioning the events leading up to it and then exploring what happened afterwards so it can be prevented

CloudsAndTrees Thu 20-Jun-13 22:30:47

Again, I have no personal experience, but it sounds like a prone restraint could be avoided if only there were the resources available to make it happen. And that would take a huge increase on staffing and provision right from the start, and more importantly, would cost a seriously huge amount of money.

It's not going to happen. And the amazing people that put themselves in the position of ever needing to restrain someone have to do what they can with the resources available to them.

Spikeytree Thu 20-Jun-13 22:34:58

Having witnessed my 5ft and barely 7 stone sister being 'restrained' for the crime of trying to open a door on a locked ward I have to say that I think restraint is used inappropriately at times. There was no way she could have got the door open, she was only trying to leave a situation where the nurse had wound her up by telling her that if her children were left with an inappropriate carer by her husband it was her own fault for being in hospital. At one point someone was kneeling on her back. I worry that if they can do that in front of her family, what were they doing when there were no witnesses there?

mignonette Thu 20-Jun-13 22:36:30


It is vital that we really hear you as a service user. The moving way in which you articulate what must have been an awful ordeal in the main makes you truly inspirational in my eyes.

And yes, not just paying lip service to a post incident de-brief ( sorry for the jargon-speak. I am institutionalised into it smile) but really using it to honestly explore why a situation deteriorated to the point of requiring such interventions, is fundamental to the development of more effective less aggressive management of hostile and aggressive behaviour. And restraint can never feel anything less than an aggressive imposition not only to the patient undergoing it but to all those who witness it.
i have, on too many occasions, had to reassure and calm other patients, visitors and passers by who have witnessed a full blown C+R incident. It is very very disturbing to witness and unfortunately staff can become inured to this aspect of it too. They focus upon their de-brief and forget the ward full of patients outside the office door.

Doyouthinktheysaurus Fri 21-Jun-13 14:35:12

I am pleased to see a few more posts sharing my view about prone restraint.

Tbh I find it a bit disturbing that people are dismissed as not being able to have an opinion because they have never had to restrain anyone or deal with a violent patient.

I think it's vital that acute services really are utterly transparent and open about what goes on. Patient welfare has to be our primary concern at all times, that doesn't change because they are trying to assault staff! Yes we have to intervene but the patients welfare remains paramount.

If physical intention is needed, 'the least restrictive intervention' is the concept we should all be following.

I don't honestly believe there is much, if any justification for the continued use of prone restraint in acute mental health and I hope things do change for our patients sake.

KatoPotato Fri 21-Jun-13 14:41:47

Taken from the 2003-2004 - House of Lords and House of Commons Joint Committee on Human Rights Death in Custody Report - Restraint in the Prone Position

“246. Restraint in the prone position has been particularly controversial because of the dangers it carries to the patient, and it has been implicated in a number of deaths.”

“248. Reliance on prone restraint is a matter of concern for compliance with Article 2, given the known dangers of this position, evidenced by previous deaths.”

“248. ……we emphasise that Article 2 requires that patients and detainees should not be placed at risk by use of this position unless absolutely necessary to avert a greater risk to themselves or others, and that they should be restrained in this position for the shortest possible time necessary. In our view use of the prone position, and in particular prolonged use, needs to be very closely justified against the circumstances of the case, and this should be reflected in guidance. Equally importantly, those restraining a detainee should be capable of minimising the risks to him or her, through techniques to ensure, amongst other things, that airways are not blocked. They should be appropriately trained to do so.”

KatoPotato Fri 21-Jun-13 14:43:45
mrsdrew Fri 21-Jun-13 15:15:13

I haven't worked on acute units for a few years but visit them regularly as part of my job. I hated using C and R and it was always used as a last resort. It is obvious that prone restraint is not the preferable course of action and should be avoided but sometimes it CAN'T be avoided. I could share many 'horror stories' as others have about sudden attacks or acts of self-harm. I don't think any of the posters say prone restraint is fine or should be used as a matter of course but sometimes it HAS to be used even for a short period. And depending in which environment you are working in, some of the service users ARE criminals and thankfully, NHS trusts are now pursuing more assault charges as it is now realised that being in hospital does not mean you can go around sexually or physically assaulting staff and other service users with impunity. And in my experience, staff do not wish to press charges against people that did not know what they were doing or could not be held responsible for their actions.

ReallyTired Fri 21-Jun-13 17:19:00

"It is obvious that prone restraint is not the preferable course of action and should be avoided but sometimes it CAN'T be avoided."

I agree that restraint can't be avoided, however lying someone face down can be avoided. There are restraint methods that are less traumatic, ie. restraining someone in a sitting position. Training may well be required to show staff better positions for restraint.

"Having witnessed my 5ft and barely 7 stone sister being 'restrained' for the crime of trying to open a door on a locked ward I have to say that I think restraint is used inappropriately at times."

What Spikeytree's sister experienced was assault. There is no justification for sticking a knee in someone's back. It was an abuse of power and the members of staff should have been disciplined. Sadly people with pychiatric problems or learning difficulties are very vunerable and are easily bullied.

People in hospital or a care home are very vunerable. Even if they are self harming, criminals, have HIV, on drugs they are still human.

Special schools in my county do not use prone restraint and they educate children up the age of 19. Infact there are NHS authorites who have a policy of not using prone restraint already. When restraint is necessary they use methods that do not cause pain to the patient/ student.

Where I used to work all physical intervention was logged and parents were told if their child had been restrained and why. There was a very clear audit trail.

While I would always think that the least restrictive form of restraint should be used, I really believe that face down restraint is sometimes necessary. I've worked for many years on a forensic ward, with patients mostly transferred from high security prisons. It is simply much harder to restrain someone sitting up or face up.

I'm sorry that people have seen restraint being used inappropriately, that is clearly not acceptable and I'd encourage you to complain. However, my experience is that no one likes restraint and it is only used when really necessary i.e. when there is an ongoing attack, or to prevent dangerous prisoners from escaping or life threatening self-harm. If a patient throws a single punch and leaves they would not be restrained.

valiumredhead Fri 21-Jun-13 18:53:58

Love? confused

ReallyTired Fri 21-Jun-13 22:11:50


Love as in the broadest sense ie. What christians mean by "love your neighbour as yourself". ie. treating those around you as you would like to be treated yourself. Admitally very few people these days are christians, but plenty of non christian people share similar senitments.

I have never had experience of restraining someone in a prone position and I have only never had experience of a sitting position or a walking restraint. Physical restraint is both physically and emotionally tiring. Certainly a sitting restraint requires a lot of stamina because you don't have gravity to help you (and often the restrainee has more stamina than the staff.)

Prolonged physical restraint in a prone position is incredibly dangerous because there is more weight on the patient. I feel that risk of killing/ hurting the patient outweighs the benefits of being less tiring for the staff. I imagine that killing the patient is a pretty swift way to finish a career.

However with a sitting restraint communication is easier and its quicker to calm the person down. Even if it requires more stamina for a sitting restraint it usually is over faster because you can make eye contact with the restrainee.

sweetestcup Sat 22-Jun-13 16:11:04

People in hospital or a care home are very vunerable. Even if they are self harming, criminals, have HIV, on drugs they are still human

I thinks thats very condescending to anyone working in a hospital like a RMN for example.

Staff are very vulnerable when being faced with a psychotic patient willing to rip their heads off too!!

ReallyTired Sat 22-Jun-13 20:29:36

"I thinks thats very condescending to anyone working in a hospital like a RMN for example."

I am sorry that you find that comment condescending; however some posters on this thread certainly need reminding that vunerable people are human.

Certain posters don't seem to care if someone suffers cracked ribs or a caridac arrest. The risk of a fellow person suffering spinal injuries is deemed OK because they are pychotic and possibly dangerous. Many patients experience post traumatic stress from a brutal restraint.

"Staff are very vulnerable when being faced with a psychotic patient willing to rip their heads off too!!"

Staff get to choose their careers, patients don't choose to be ill. Risks are far less with proper training and reasonable patient to staff ratios.
Staff can leave the ward where as the patients don't have that kind of freedom.

It would be interesting to know what proportion of people who are restrained face down are actually violent to someone else. (Rather than trying to escape, self harm, damage property or refusing to take medication.)

thetrackisback Sat 22-Jun-13 21:53:48

Face down restraint has been banned in some mental health trusts and we are trained never to do it. Obviously if you are in a situation of danger the person may end face down but there are techniques to turn the person over of needed. What is worrying is the disparity between health trusts. Some health trusts do use restraint to soon and not as a last resort and this is illegal as it would be classed as unreasonable force.

Psychotic does not mean violent. I am horrifed at some of the comments on here.

Kasterborous Sat 22-Jun-13 23:39:31

I worked in a hospital for patients with mental health issues and very challenging behaviours. We had control and restating training and yes we were taught not to restrain anyone face down. But equally we were allowed to use reasonable force if it was for their or our own safety. On the odd occasion face down restraint occurred we turned them over when possible. We did have a couple of quite obese patients and they could never be restrained face down in any circumstances. If someone is throwing furniture at you or going for your throat you have to act.

ReallyTired Sat 22-Jun-13 23:53:49

Going back to the clip on the BBC website

Naomi Ball was a child when she was restrained face down. (aged 17 years old.) Restraining a 17 year old child face down in the special school I used to work in would be gross misconduct. Why is it OK to restrain a pychotic child in a face down position, but not OK to restrain an autistic school child of the same age?

The hospitals that thetrackisback and Kasterborous have reasonable restraint policies. There is a difference between a patient ending up in a face down positon and being turned over as quickly as possible and diliberately putting someone in a face down position. Restraint is sometimes necessary, but it needs to be safely done.

fluffydressinggown I think that you are very brave to read this thread as some of the attitudes on this thread are not much better than biblical times when people thought that pychotic people were pocessed by demons.

I hope you are well and this thread is not upsetting you too much.

I am fully aware what psychotic means thank you.

MillieN Mon 24-Jun-13 18:05:59

Sadly, restraint is needed occasionally. But to say that at times it needs to be face down is just not true. I live in an area where Mental Health Services have a very different approach. I used to work in the service myself and know from experience that the process we now call RESPECT which underlies all our treatments on the ward and in the community has changed the service we have tremendously. Nurses have commented that they can now be"nurses and not jailors " Patients are not scared to go to hospital and can even learn about the process for themselves. Service users participate in staff training and injuries have been greatly reduced. Google Respect and NAVIGO to find out more about how this worn and how it came about. Those who tell you there is no alternative have not done their homework. Respect is not the only solution on offer, but it is an excellent system that works. You really should check it out.

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