Synopsis of the literature

2008 RCN guidelines “Lets talk about Restraint” - although past review date this document on page 9 suggests through 3 case studies that the following questions should be considered…

if restraint (clinical holding) is used it should be…

• the least restrictive option
• as safe as possible
• for as short a time as possible

What does this mean? How can/do you currently evidence this? Who decides?

2013 RCN Dignity in Healthcare for people with a learning disability offered using sedation as an example of good practice (p7).

2017 DoH Reducing the need for Restraint and Restrictive Intervention… discusses whether individuals should be restrained - i.e. page 40/41.

2018 University of Bristol CIPOLD (Confidential Inquiry into Premature of People with a Learning Disability), identified (p7) that problems with routine diagnosis and treatment has been identified as a common reason for premature deaths.

Public Health England Blood tests for people with learning disabilities: making reasonable adjustments (2017)

• Clinical holding should be used as infrequently as possible and only when all other approaches have been tried or considered (page 8).
• Clinical holding must be underpinned by an ethos of caring and a respect for the individual’s rights (page 9).
• There should be a risk/benefit assessment prior to the intervention - this should include careful consideration of whether the procedure is necessary and if there are any alternatives to clinical holding.
• There must be a sufficient number of staff who are appropriately trained and confident in the process.
• Accurate record keeping is essential - this should include why the intervention was necessary and details of what it involved

How can/do you currently evidence this? Who decides?

Rationale

There are no clear documentation, articles, frameworks or total agreement about the clinical holding of children, young people or adults for procedures. Therefore we have developed the following framework to help you with planning, decision making and documentation to support clinical holding techniques.

This framework should be used for any hold that you use in practice and it’s a great way of talking to the patient, carers/parents, students/apprentices, etc., about preferences for holding and a useful means to help with documentation

We know from our research and experiences, and it has been identified by colleagues in other countries, that holding is not mentioned in documentation (apart from some countries such as Turkey requiring parents signatures). This is because clinical holding regardless of what terminology is used is not regulated in any country. We can only refer to our professional codes, ethical frameworks and the international rights of the child to guide our practices.

Download the Framework for Clinical Holding (PDF)

Examples

We have completed two frameworks as examples for you.

Evaluation of the clinical hold

• Do I feel satisfied with my care delivery?
• Could I justify my decisions to a 3rd party?
• If I was repeating this care, would I do anything differently, and if so, what would this be?
• How flexible have I been in my decision making?
• Using the Clinical Holding website enables the user to document and reference the holding technique as well as the procedure or clinical intervention.

Resources

• The Autism Treatment Network Phlebotomy Toolkit for providers Treating Children with Autism (PDF)
• Public Health England’s Blood tests for people with learning disabilities: making reasonable adjustments

References

• Autism Speaks (ND) The Phlebotomy Toolkit for Providers Treating Children with autism (PDF)
• McKnight, J. (2016) The Justification and Use of Restrictive Practices: The need to include service user views and preferences (PDF)
• Page, A., & McDonnell, A, A., (2013) Holding children and young people: defining skills for good practice British Journal of Nursing, 22(20):1153-1158
• Page, A., & McDonnell, A, A., (2015) Holding children and young people: identifying a theory practice gap British Journal of Nursing 24(8): 378-382
• Page, A.; McDonnell, A, A.; Gayson, C.; Moss, F.; Mohammed, N.; Smith, C and Vanes, N., (2015) Clinical holding with children who display behaviours that challenge British Journal of Nursing 24(21):1004-1009
• Page, A., (2015) Holding children and young people for clinical procedures: moving towards an evidence-based practice. PhD dissertation, Birmingham City University
• Page, A., Warren, A., and Vanes, N., (2017) Clinical holding an evaluation of a website developed through a collaboration between Birmingham City University and Birmingham Children’s Hospital NHSFT Nursing Children and Young People, 29(2); 20-24
• Page, A., Elven, B., McDonnell, A, A., Warren, A., Vanes, N., and Seabra, S (2019) Holding children and young people for procedures: ethical guidance for healthcare practitioners Journal of Nursing Children and Young People, 31(4);28-33
• Public Health England (2017) Blood tests for people with learning disabilities: making reasonable adjustments London, PHE Publications
• Royal College of Nursing (2010). Restrictive physical intervention and therapeutic holding for children and young people; Guidance for Nursing Staff. London: RCN
• Svendsen, Pedersen , Moen & Bjork (2017) Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians International journal of qualitative studies on health and well being 12 (1),1-11
• Valler-Jones, T., & Shinnick, A., (2005) Holding Children for invasive Procedures, Paediatric Nursing 17(5):20-2

Guidlelines

• 2008 RCN guidelines “Lets talk about Restraint” - although past review date this document attempts to distinguish justifications for using restraint and good practice (although the emphasis is on emergency care/responding to a life threatening illness
• 2010 RCN guidelines Restrictive physical interventions and the clinical holding of children and young people: Guidance for nursing staff
• 2013 RCN Dignity in Healthcare for people with a learning disability
• 2013a RCN Draft guidance on the minimisation of and use of alternatives to restrictive practices in health and adult social care, and special schools
• 2016 RCN Positive and Proactive care - Reducing the Need for Restrictive Interventions
• 2017 DoH Reducing the need for Restraint and Restrictive Intervention
• 2017 Public Health England Blood tests for people with Learning Disabilities: Making Reasonable adjustments
• 2018 University of Bristol CIPOLD (Confidential Inquiry into Premature of People with a Learning Disability)
• 2019 Restraint Reduction Network standards
  

  The Restraint Reduction Network Training Standards 2019 have been written for training services delivered to education, health and social care services across the UK including services that support people with autism, learning disabilities, dementia and mental health conditions