Applying Manual Handling criteria
The physical handling of any load or person is regulated under the Manual Handling Regulations 1992.
The Regulations and Associated Guidance paragraphs establish a clear hierarchy of measures:
1: Avoid hazardous manual handling operations so far as is reasonably practicable. This may be done by redesigning the task to avoid moving the load or by automating or mechanising the process.
2: Make a suitable and sufficient assessment of any hazardous manual handling operations that cannot be avoided.
3: Reduce the risk of injury from those operations so far as is reasonably practicable. Particular consideration should be given to the provision of mechanical assistance. Where this is not reasonably practicable then other improvements to the task, the load and the working environment should be explored.
The Manual Handling Regulations require that any physical intervention procedure staff are using to carry out a task should be assessed in such a way as to reduce forseeable risk.
It seems sensible that the use of a device to assist a hazardous manual handling procedure be considered in the ‘range of options’ available to the staff. Of course, staff already use a device to assist in another hazardous manual handling activity all the time – the hoist!
If a hoist is considered essential for the manual handling of a person who requires lifting, why then would the use of a device to hold them during a violent episode be considered ‘inhumane or degrading’? Particularly when one considers that the use of a device can be in the ‘best interests’ of the person being restrained because it may:
- reduce the time during which staff struggle to gain control
- reduce the amount of time the person is restrained for
- reduce the overall amount of time which the actual task (e.g. personal care) takes
The ERC and the ERB, when used in conjunction with one another, can make the movement or handling of a violently resisting person much safer because of the effect of putting ‘handles on the body’ for moving & handling procedures.
Applying the ‘Duty of Care to Staff’ criteria
Some will be concerned that the use of restraint devices is against their caring ethos. They see the use of devices to restrain as somehow a ‘step backwards’ in terms of care, or somehow intimidating or degrading for the person concerned. Perhaps managers are even afraid that a care inspector might see them using a restraint device and decide that it is ‘abuse’.
There is a case which came to my notice early in 2013 which illustrates how the courts treat the difference between the legal obligations of employers/managers and the ‘caring ethos’ which sometimes clouds decision-making in the care sector.
The case was of a young woman who was working for Bradford NHS trust and who almost lost her sight because of the violent spitting behaviour of her client. Known to spit when frustrated and aggressive, he spat in her face one day, which resulted in an eye infection and necessitated an eye operation to save her sight.
In the court case which ensued, her union and the prosecution lawyers successfully argued that there was no adequate system in place for recognising the risks staff faced with that service user and how best to control those risks. It was specifically mentioned that the staff should have been provided with protective equipment (eye goggles ) to deal with the risk.
It takes little imagination to guess at the reason why management had NOT considered the use of the goggles or spit-masks. In fact I have been involved in meetings where management and staff have discussed the use of a variety of protective equipments to stop staff from being spat at or bitten. Always the issue arises: “would that be a dignified or humane way to treat the service user, in line with our caring ethos?”.
This case severs to remind us all that a decision not to use an ‘obvious’ risk-control method may need to be defended in court if a situation results in harm, injury or death.
To return to the main thread of our discussion here then, my advice is that managers should be:
- actively making themselves aware of risk-control methods which are available in their sector
- assessing the risks facing their staff in an objective way
- considering the use of risk-control methods while considering their legal obligations to BOTH staff and clients
- objectively documenting the reasons why they have decided to use or not use those methods.
My caution here: the choice NOT to use an available risk-control method would need to be carefully, objectively documented in a suitable and sufficient risk assessment.
Applying the ‘Best Interests’ criteria
I often hear that a care home has a resident for whom it becomes necessary to carry out personal care when they are in bed AND they are resistant to that care.
My recommendation has always been that cleaning or caring for an actively resisting mobile person in a bed will require 5 staff. My best example of this is the case of a client in a private hospital I work with who sometimes suffers life-threatening respiratory distress, but who violently attacks the staff who attend to him to save his life.
The procedure we teach staff for this task requires 4 staff to engage and hold the subject and then 1 staff is able to safely carry out the personal hygiene care task. In my opinion, with a mobile person who can move their limbs freely, this is the minimum requirement to carry out the task safely.
One consideration here is that a team of 5 staff with a good plan can complete a cleaning task like this in less time with more safety and comfort for the person than a team of 2 staff can with less control and less safety. A team of 5 staff can complete the task faster by far than a struggling team of 2.
Staff often resist the idea that this task might need so many people, however if we ask the question: what is in the resident’s best interests? then I think the answer would be: “To be subjected to any invasive procedure for the minimal amount of time necessary”
Is it possible that the least intrusive response to a person’s presented behaviour may be the use of a restraint device like Soft-Cuffs or ERB?
In summary then, I believe that the ERB and ERC can serve a very useful purpose for healthcare staff who are facing particularly difficult decisions about how to maintain appropriate care of vulnerable people and at the same apply the right level of control in regard to the risks they face when those clients are violent or combative.
From the point of view of staff, clients and management, these devices should be considered carefully in the light of all the information, guidance and legalities which attend to this complex area. However, complex as it is, I believe that there are situations in which these devices can make the care of vulnerable people both safer and more suited to individuals’ needs.
I have one final example of how these devices could be both appropriate and highly useful. I recall hearing that at one NHS trust, a client who has recurring episodes of violence which necessaitate staff having to control him in prolonged holding, the staff asked him about these devices. They involved him in a presentation and demonstration of the devices use, and asked for his opinion as to how they might be used to better deal with his episodes of violence. I think it is a great example of a staff team not just being satisfied with the status quo, and also actively looking for a better way, in cooperation with their client. Bravo!
Gerard O’Dea is a conflict management, personal safety and physical interventions training consultant. He is the training director for Dynamis, a specialist provider of personal safety and violence management programmes and the European Adviser for ‘Verbal Defense and Influence’, a global programme which addresses the spectrum of human conflict. www.dynamis.training