Restraint interventions are commonly used within learning disability services and much research has explored their effectiveness in the management of challenging behaviour (see Heyavart et al. 2014 for a review).
However, studies rarely explore the emotional and ethical aspects of their use. In the second of a two-paper series, Heyavart and colleagues (2015) explore how restraint interventions are experienced – from the perspective of staff or family carers using the interventions, as well as people with learning disabilities who receive them.
8 online databases were used to retrieve articles, as well as manual searches of journals and reference lists and citation indexes. Papers were selected if they depicted the views, emotions or perspectives of staff or family carers and/or clients concerning restraint interventions used to manage challenging behaviour among people with learning disabilities . In total 17 papers were selected for the review.
Mixed methods were then used to synthesise this literature; a statistical meta-analysis alongside qualitative techniques to explore themes and patterns. Synthesis of this information was used to create an evidence-based model to describe the relationship between people using the restraint interventions, people receiving the restraint intervention, their interactions, and wider variables affecting the use of these interventions.
Most of the papers explored restraint interventions from the perspective of the person with learning disabilities receiving the intervention. Fewer papers explored the staff or family carers’ perspective, however the authors found that these carer studies were more in depth than the learning disability papers, providing space for exploration of complex feelings.
People with learning disabilities sometimes did not understand why restraint interventions were used, and felt that stopping or preventing the use of the intervention was out of their control. A wide range of emotions were associated with before, during and after an intervention and the authors suggest that people using the intervention perhaps don’t realise the negative emotional impact they can have.
Staff and family carers often felt overwhelmed by instances of challenging behaviour, again feeling a range of emotions before, during and after an event. Their preparedness and the predictability of a situation helped reduce the use of inappropriate restraint interventions. Moreover, use of restraint intervention were affected by the relationship between clients and staff or family carers, and the influences they have on one another.
Carers and clients often make inaccurate judgements of the others’ motives, control over their actions, and understanding of the situation which can mean restraint interventions are more likely to be used inappropriately.
In addition, the perceived (non)acceptability of different restraint methods affected their use. Interestingly, methods which were most acceptable to carers were not the same methods which clients found most acceptable.
For example, one paper in the review described how clients rated use of ‘face-up’ interventions as most acceptable, while carers preferred ‘face-down’ interventions. It is easy to see how situations requiring restraint may become exacerbated through this lack of understanding and poor communication.
The authors suggest that to improve the way challenging behaviour is managed, it is important to improve understanding, communication and relationships between staff or family carers, and clients. Discussing and evaluating incidents requiring restraint may facilitate greater understanding on both sides, and promote collaborative management of challenging behaviour.
Training and guidelines in best practice were seen to be an essential resource to support staff and carers to use these restraint interventions appropriately.
Strengths and Limitations
The authors used a lengthy and (at first glance) complicated analysis process, however they describe the process clearly and their use of tables and diagrams help to further illustrate their analysis. The model they have established synthesises a thorough analysis of the available literature and has a clear practical use.
The practical application of their work is further enhanced by a set of guidelines for best practice using restraint interventions, drawn from the literature, which care settings could incorporate into their working practices.
However, their model has been developed from a somewhat limited literature base. The majority of papers in the review were for the management of physically aggressive behaviour – clearly not encompassing the full spectrum of ‘challenging’ behaviours which could lead to use of restraint interventions. Indeed, in their previous paper (reviewing efficacy of restraint interventions) the authors found that the majority of papers referred to self-injurious behaviour.
Moreover, papers which explored clients’ experiences had mostly male participants, the large majority of whom had mild-moderate learning disabilities. While these perspectives are important, they may not be representative of the wider learning disability population – particularly people with more severe learning disabilities or those who experience restraint interventions for reasons other than aggressive behaviour.
This review drew upon available literature to emphasise the ethical and emotional issues surrounding the use of restraint interventions. They highlight the many factors which influence use of restraint from staff or family carers’ and clients’ perspectives, particularly how important it is to recognise the emotional impact on both sides and how the relationship between carers and clients influences the use of restraint interventions.
The authors use their findings to outline guidelines for best practice and produce a model depicting the interactions and factors which surround the use of restraint interventions. Their model depicts the complex network of variables involved in the restraint intervention process, and may have positive impacts on carer and client well being by helping people reflect on their use of these methods.
The authors acknowledge that when conducting research with people with learning disabilities it can be difficult to “dig deep” – both for the participant in terms of expressive communication and understanding, and for researchers in terms of accessibility and resources available. Certainly this paper has highlighted how experiences of restraint interventions for people who have severe – profound learning disabilities are hugely under-represented. It is the responsibility of researchers to establish creative ways to fill these gaps in the evidence base.
Heyvaert, M., Saenen, L., Maes, B. and Onghena, P. (2015), Systematic Review of Restraint Interventions for Challenging Behaviour Among Persons with Intellectual Disabilities: Focus on Experiences. Journal of Applied Research in Intellectual Disabilities, 28: 61–80 [abstract]
Heyvaert, M., Saenen, L., Maes, B., & Onghena, P. (2014). Systematic Review of Restraint Interventions for Challenging Behaviour Among Persons with Intellectual Disabilities: Focus on Effectiveness in Single Case Experiments. Journal of Applied Research in Intellectual Disabilities, 27(6), 493-510 [abstract]