Clinical Holding Guide

Further information for health care staff

Background

As part of a research project, student nurses and healthcare professionals (nursing, radiography, theatre, phlebotomy, play specialists, neuro scientists, lecture practitioners, education/learning team and medical staff) were interviewed to identify what their teaching and learning needs are regarding the application of holding techniques (also known as therapeutic holding, clinical holding, supportive holding, restraint and restrictive holding).

Healthcare staff and student nurses told us that they:

Want to be shown how to hold the child effectively, using best practice and...
Find it difficult to interpret existing images (such as photographs and posters) found in text books, journal articles, local guidelines or policies.

Holding children and young people for clinical procedures is an important area of practice, but research discussing it is sparse. Nurses and healthcare staff implement procedures that can cause the child or young person to experience distressing sensations (Snyder, 2004). Many procedures require the child or young person to be still and which the implementation causes discomforting or painful sensations. There is a lack of evidence of what healthcare staff actually do in practice when faced with a child or young person who finds it difficult to sit still during the clinical procedure or medical examination (Page and McDonnell, 2013). This project specifically looked at techniques used by healthcare staff and through formal discussions with them, explored holding issues around each procedure; the purpose of the holding technique; the characteristics and risk (in terms of safety, child risk factors and effectiveness). Our aim is to highlight holding techniques which are currently in use, for healthcare professionals, student nurses, student radiologists, student dental nurses and parents to use them in a safe, consistent manner and that healthcare staff and students gain confident in their knowledge and practice on this subject.

At present the advice given about holding practices is not evidence based. Research by Page and McDonnell (2013) has identified that there is a possibility that some healthcare staff and students may have picked up bad habits and apply holding techniques in different ways. The move towards evidence based practice requires a conscientious, explicit and judicious use of current best evidence in decision making. This includes questioning of practices, collecting data on techniques in use, comparing techniques, appraising techniques and evaluating their use in practice. The work by Andrea Page for her PHD will offer a framework of scientific research and evidence in the near future. The feedback form within this tool is intended to help in this process of questioning, data collection, comparison, appraising and evaluation.

We hope that you will find the 3D images a useful reference to aid learning, memory and retention of skill. We would also be delighted to receive feedback from you.

Introduction

“Many nurses do not receive specific training in techniques of restrictive physical intervention and therapeutic holding and as a result lack confidence in using these techniques. Greater emphasis needs to be placed on enabling nurses to acquire knowledge and skills through the provision of locally based training programmes. It is recommended that organisations undertake an organisation –wide risk assessment to address particular risks in each clinical area and thus identify staff training needs” (RCN 2010 page 5).

Within clinical practice it may be necessary in some circumstances to use physical or mechanical techniques (also known as therapeutic holding, clinical holding, supportive holding, restraint, restrictive holding) in order to help a child or young person stay still for a medical procedure or examination, keeping them safe and ensuring that they receive appropriate care. At present because there is no agreement on the term used to describe this practice and a lack of consistency in definitions, this website will use the terms ‘holding’ and ‘clinical holding’ interchangeably until such agreement has been achieved.

The context may be that the infant, toddler, child or young person lacks capacity and the ability to understand and co-operate with the specific procedure or examination – this could be due to medical condition, medication, or because of their age. Other context may be that the child or young person does not understand the need to remain still during the procedure or examination; the child or young person has involuntary movements or an inability to control their movement and needs help to remain still; or the child or young person may have asked for help to remain still.

Purpose

Collaborative preparation and planning involving healthcare professionals, the child or young person and parents/carers, students, should be the essential element and consideration should be given for the maturity of the child/young person and their ability judged to be able to give consent to treatment. Healthcare professionals must recognise that on occasion’s children or young people may have to be held in a safe and controlled manner for a variety of procedures examples would include: taking blood samples, insertion of intravenous catheters, lumbar puncture removal of plaster of paris, preparation for theatre, medical examination, suturing/gluing of wounds, dental examination/treatment, cleaning wounds, cleaning burns. This is not an exhaustive list, but gives some examples of the many procedures being undertaken where holding may be required. Careful consideration of whether the procedure is really necessary and whether urgency in an emergency situation prohibits exploration of alternatives should be made by the Healthcare professional. A flowchart to describe a process of decision making in relation to the application of holding techniques is included in this section.

Clinical Holding is the proactive immobilisation of a part of the body to which a procedure is carried out, for example holding an arm from which blood is taken in order to prevent reflex/withdrawal and consequently pain/distress or injury to the child/young person. Holding of a small child requires healthcare professionals/students to consider:

The benefit – any actions or decision to use clinical holding must be for the benefit of the child or young person (identify the potential benefits, the risks and all alternatives. Also identify the consequences of not receiving the proposed medical procedure or medical examination).
The least restrictive option – the clinical holding technique chosen must be the minimum necessary to achieve its purpose.
Effective preparation successfully reduces the need for undue force when using clinical holding. This includes assessing whether the timings of the procedure or examination could be changed to take into account medication or other aspects of routine which may be important in ensuring effective treatment outcomes for the child or young person. This also includes the use of other strategies which may be beneficial, such as, the use of play therapy; music therapy; relaxation techniques; distraction techniques and specific communication strategies that the child or young person may use. Giving the child time to play may enable them to explain their fears.
Seek consent with parental involvement.
Make an agreement with the child and/or parent about what holding techniques and methods will be used, when and for how long. This should be documented in care plan or notes.
Ensure parental presence and involvement if they wish to be involved. Parents should not be made to feel guilty if they do not wish to be present during the procedure. Healthcare professionals/students should explain to the parent what their role is throughout the procedure for example: - how to support their child. Consideration should also be given to supporting the parents during and after the procedure as they maybe distressed at seeing their child upset.

De-escalation using both verbal and non-verbal communication skills in combination may minimise distress.

Before clinical holding is considered the healthcare professional should consider:

Assessment of the clinical situation.
The most suitable clinical holding technique for the child and the procedure to be undertaken (this means the option that restricts the child or young person’s movement as little as possible).
The environment.
Time of the procedure or medical examination.
The child/young person’s behaviour.
The child/young person’s underlying medical conditions.
Child/young person’s age.
Child/Young person’s mental capacity
Duty of Care.

Understanding a child/young person’s behaviour and responding to their individual needs should be at the centre of patients care. Underlying causes to behaviour and response by the child/young person could be:

Fear, phobia.
Medical conditions – such as hypoxia, hypoglycaemia.
Sensory response – for example, how the child or young person experiences touch.
Treatment refusal as part of adolescent behaviour.
Medication.
Alcohol or substance influences.

Once the reason for the behaviour is identified appropriate strategies can be put in place, this may include treating the underlying medical cause, play and distraction techniques.

Risk and risk assessment

McDonnell (2008), Martin et al (2008) and the BILD Code of Practice (BILD 2010) recommend that a risk assessment is undertaken to discuss the suitability of the techniques for the different ages and sizes of the child and young person. This risk assessment will identify the psychological impact of any techniques, any risks of potential harm to the people doing the holding, the risk of harm to the child or young person, the risk of the technique impeding the child or young person’s breathing.

Documentation must also identify how the techniques should be taught, that they are safe to be used and that they have been reviewed. It is crucial that any documentation provides evidence that the techniques used:

do not intentionally inflict pain.
avoid vulnerable parts of the child’s body.
avoid hyperextension and hyperflexion of limbs and joints.

Johnson (2007) writes that once physical restraint has begun the risk to the child accumulates to include potential compromise of respiratory function. Although the focus of his article is the restraint of children within child and adolescent mental health settings; there are relevant issues raised which should be considered when performing clinical holding techniques.

The airway in a smaller child is likely to collapse with hyperextension or hyperflexion of the neck because the cartilaginous rings around the trachea are not fully developed.
If the child is screaming there is a decrease in pressure in the trachea which can result in the airway collapsing.
Any prone positioned restraint or clinical holding will place the child at risk from positional asphyxia because the child will always be breathing against the weight of their upper body.
The issue of the child struggling or being anxious is also documented with research from Rico et al (2005) who suggest that the anxious or struggling child regardless of position causes an adrenal catecholamine release, effecting heart rate. However if the child hyperventilates this can decrease carbon dioxide and may temporarily affect the child’s heart rate.
Children who have asthma or who are diagnosed as being obese need to be treated with even more care.
Respiratory disease such as asthma or cystic fibrosis can alter the shape of the chest (Devitt and Thain 2011).
Oedema or swelling in airways due to irritants or infections may narrow the child’s or young person’s airways. This can affect the effort that the child uses to move air into their lungs (called airway resistance) (Devitt and Thain 2011).
The anatomical differences between children and adults should also be taken into consideration – children rely completely upon their diaphragm to breathe. Major organs such as the liver and spleen are not protected by the child’s ribs and they can easily be crushed or dislodged during restraint, which may also dislodge the diaphragm and compromise breathing.
Johnson (2007) cautions against using restraint with young people because although their airways are more stable and their rib cage provides a more rigid protection the young person is heavier.
Children can maintain their normal vital signs even when experiencing a distressing ordeal for a much longer time than adults are able to, however when their reserves are exhausted the child’s vital signs will decline, indicate asystole (also known as flat-lining), respiratory arrest and vascular collapse. Pulse oximetry (if used correctly and with caution) may be valuable to determine the percentage of oxygen circulating blood through the capillary bed.
Johnson (2007) also considers how the child is positioned during the restraint and how this affects their respiratory function. Any restraint, where the chest or abdominal wall is restricted and supine positioning can compromise the respiratory function of the small child (Masters et al 2002). Sparks et al (2007) state that the child who can see what is happening to them experienced less distress in their small scale empirical study.
Johnson (2007) warns that some psychotropic medications can affect breathing.

What techniques are deemed appropriate

The effectiveness of clinical holding techniques has not been scrutinised within literature, although research looking at comparing the child being held in a lying down position to an upright one has been documented in terms of satisfaction, comfort, stress reduction (Kurfis Stephens 1999 and Sparks et al 2007).

The techniques that are documented within this resource in 3D are those which have been risk assessed as being safe, effective and appropriate for use by the team involved in this research project.

Andrea Page and Andrew McDonnell, with colleagues from Birmingham Children’s Hospital will be undertaking further research to review and catalogue holding techniques in use within the United Kingdom with a view to leading discussion and identity age appropriate techniques, techniques suitable for young people and those with ‘challenging behaviours’. This could also lead to establishing a practice development model where experts, healthcare staff, the child/ young person and their parents could discuss concerns, literature, differing professional opinions as well as develop mechanisms to review and risk assess holding techniques.

Limited force

How much force used to hold a child is often used as a measurement to distinguish between a clinical hold and a restraining hold (RCN 2010 and Jeffery 2010), between a technique viewed as supportive (Jeffery 2010) and one that is viewed as abusive (Folkes 2005). However how much force is used is a subjective measure, and published opinion papers suggest that the following are also taken into account:

whether there are marks left on the child/signs of redness/bruising (Jeffery 2010)
the child’s distress levels (Jeffery 2010)
the child’s pain levels
the number of people and gender required to complete the holding (McGrath et al 2002 and Hull and Clarke 2010)
and consent (Jeffery 2010).

The lack of research in this area and the subjectiveness that surrounds our understandings about the use of force has been the main reason why many people prefer to use the terms ‘restraint’ or ‘restrictive holding’ to describe holding.

The techniques that are documented within this resource in 3D are those which have been risk assessed as being safe, effective and appropriate for use by the team involved in this research project.

References

BELVISIO, M, DE DONNO, A. VITALE, L. AND INTRONA, F. Jr. (2003) Positional asphyxia: reflection on 2 cases American Journal of Forensic Medicine and Pathology 24(3): pp. 292-297.

BRODESKY, J. B., OLDROYD, M. WINFIELD, H. N. and KOZLOWSKI, P. M (2001) Morbid Obesity and the prone position: A case report Journal of clinical Anaesthesia, 13 (2): pp. 138-140.

DEVITT, P. & THAIN, J. (2011) Children and Young People’s Nursing made Incredibly Easy, UK First Edition. London: Lippincott Williams and Wilkins.

EGI, M. HIRASAKI, A. NAGAI, M. MATSUSHITA, M. MATSUDA, R. and SETO, K. (2004) Case of circulatory depression in an obese patient in prone position during general anesthesia Masui, The Japanese Journal of Anaesthesiology, 53(9): pp. 1035-1038 cited in Johnson, T. D. (2007) Respiratory Assessment in Child and Adolescent Residential treatment Settings: Reducing Restraint-Associated Risks Journal of Child and Adolescent Psychiatric Nursing, 20(3): pp. 176-183.

FOLKES, K. (2005) Is Restraint a Form of Abuse? Paediatric Nursing, 17(6): pp. 41-44.

JEFFERY, K. (2010) Supportive holding or restraint: terminology and practice. Paediatric Nursing, 22(6): pp. 24–28.

JOHNSON, T. D. (2007) Respiratory assessment in child and adolescent residential treatment settings: reducing restraint-associated risks. Journal of Child and Adolescent Psychiatric Nursing, 20(3): pp. 176-183.

KURFIS STEPHENS, B. BARKLEY, M.E. and HALL,H.R. (1999) Techniques to comfort children during stressful procedures. Accident and Emergency nursing; 7; pp. 226-236.

NURSING AND MIDWIFERY COUNCIL (2008) The Code Standards of conduct, performance and ethics for nurses and midwives, London: NMC.

NURSING AND MIDWIFERY COUNCIL (2009) Guidance on Professional Conduct for Nursing and Midwifery students, London: NMC.

MARTIN, A. MCDONNELL, A. LEADBETTER, D. and PATERSON, B. (2008) Evaluating the Risks associated with Physical Interventions In ALLEN, D. (ed.) Ethical approaches to physical interventions Volume 2 Changing the agenda Worcester, BILD pp.37-53.

MCDONNELL, A, A. (2007) A proposal for the development of an assessment tool to evaluate physical interventions. BILD available at http://www.bild.org.uk/yjb_project/

MCGRATH, P. FORRESTER, K. FOX-YOUNG, S. and HUFF, N. (2002) ‘Holding the Child Down’ for Treatment in Paediatric Haematology: The ethical, Legal and practice Implications. Journal of Law and Medicine, 10(8): pp. 85-96.

MCGRATH, P. and HUFF. N. (2003) Including the fathers perspective in holistic care. Part 2: Findings on the fathers’ hospital experience including restraining the child patient for treatment. The Australian Journal of Holistic Nursing, 10(2): pp. 5-10.

PAGE, A. and MCDONNELL, A.A. (2013) Holding children and young people: defining skills for good practice. British Journal of Nursing, 22(20); pp. 1153-1158.

RCN (2008). “Let’s talk about restraint”: Rights, risks and responsibility. London: RCN.

RCN (2010). Restrictive physical intervention and therapeutic holding for children and young people; Guidance for Nursing Staff. London: RCN

RICO, A., J. PRIETO-LLORET, J. GONZALEZ, C. and Rigual, R. (2005) Hypoxia and acidosis increase the secretion of catecholamines in the neonatal rat adrenal medulla: An in vitro study American Journal of Physiology. Cell Physiology 289(6), C1417-C1425 cited in Johnson, T., D., (2007) Respiratory Assessment in Child and Adolescent Residential treatment Settings: Reducing Restraint-Associated Risks Journal of Child and Adolescent Psychiatry Nursing, 20(3); pp. 176-183.

SNYDER, B.S 92004) Preventing Treatment Interference: Nurses and Parent’s Intervention strategies. Paediatric Nursing, 30(1); pp.31-40.

SOUD, T. E. and ROGERS, J. S. (1998) Manual of Pediatric Emergency Nursing (1st Edition ) St Louis: Moseby cited in Johnson, T. D. (2007) Respiratory Assessment in Child and Adolescent Residential treatment Settings: Reducing Restraint-Associated Risks Journal of Child and Adolescent Psychiatric Nursing, 20(3): pp. 176-183.

SPARKS, L.A. SETLIK, J. and LUHMAN, J.(2007) “Parental Holding and Positioning to decrease IV distress in young children: a randomised controlled trial” Journal of Paediatric Nursing, 22(6); pp. 440-447.

SHINNICK-PAGE, A. CASH, S. and SEABRA, S. (2008) Standards for Clinical Holding Paediatric Nursing 20 (5): pp.8.

THE FACULTY OF DENTAL SURGERY (2012) Clinical Guidelines and Integrated care Pathways for the Oral Health Care of people with Learning Disabilities The Royal College of surgeons of England

VALLER-JONES, T. and SHINNICK, A. (2005). Holding children for invasive procedures: preparing student nurses. Paediatric Nursing 17(5); pp. 20–22.

Nursing & Midwifery Council (2018). The code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. London: Nursing & Midwifery Council

NMC (2018a) Standards of proficiency for registered nurses - The Nursing and Midwifery Council (nmc.org.uk)

Developed by

Andrea Page Associate Professor, Birmingham City University PhD, MSc, PG Cert, RNLD, RT, FHEA

Nicola Vanes Clinical Research Manager, Birmingham Children's Hospital EN(G) ; RGN (Adult); Prince 2

Decision making

Click to download ‘A Flowchart For Decision Making’ (PDF)