Category Archives: Challenging Behaviour

Physical Restraint: The Story Behind the Stats

As Mind publishes survey data and calls for a ban on face-down restraint, The Stuff of Social Care looks at the issue from the point of view of those doing the restraining

It’s been a long time since I last took part in physical restraint, but for many years I did work in environments where the need to prevent harm was part and parcel of a nurse’s working day.

For the most part we relied on the first resort. Talking, listening, reasoning, observing. Using a rapport that may have been built up over a period of time, and developing skills that were fundamental to working with highly distressed, agitated people. For most of my nursing career I was lucky enough to work in well-staffed forensic units where staff and patients knew each other well, and where the very thought of an agency or locum nurse was unimaginable.

But at times the last resort was unavoidable. Most of the trained, professional staff I worked with would much rather not use physical restraint. Like me, they would loathe the idea of holding down another human being to inject them with powerful drugs. But when all else has failed, or extreme harm was imminent, or where leaving a severely psychotic man or woman unmedicated would almost certainly leave them more terrified, confused and at risk than they already were, then I for one would not lose any sleep restraining that individual.

By the time I had qualified as a nurse, physical restraint had gone from the often chaotic bundle of arms legs and torsos of my student days toward a set of techniques called Control and Restraint (C&R), a Home Office approved means of managing physical aggression. I along with my colleagues attended regular training in C&R. We turned up at sports halls in trackies and trainers spending hours and days learning and practising the management of physical aggression.

A major (and rather unpopular) part of the training involved role-playing ‘the patient’ and being subjected to the procedures oneself. C&R was based on a 3-person team immobilising the patient. It used a certain amount of discomfort and even short bursts of pain to contain violent people, a fact which we as the role player would be only too well aware. Some of the techniques we learnt involved immobilising the patient face-down on a floor or bed. The reasons for this were that a) the person on their back can fight back much more effectively than if they are face down, and b) saliva and teeth make very potent weapons when they belong to a person who really, really doesn’t like being held down on a floor by several nurses. A key part of the 3-person team was the ‘head’ man or woman, whose job was to ensure minimum discomfort for the person on the floor and protect their airway.

But apart from the actual physical techniques, a fundamental of the training was that physical restraint was absolutely a last resort once every other strategy had failed, or where danger was imminent.

There are those who believe that physical restraint of the mentally ill is little more than state-sponsored thuggery, or who wonder whether restraint is necessary at all. Well, physical restraint is a necessary part of mental health care at times. That’s an undeniable fact, but it’s easy to see why and how restraint gets such a bad press, and why bodies such as Mind need to spend time, money and effort surveying it’s use.

We need go little further than Winterbourne View to acknowledge the presence of thugs masquerading as care professionals. From the very first emergence of the lunatic asylum, the opportunity to get paid for wielding power, authority and physical dominance over others has always proved attractive to a certain type of psychopath.

But there are much deeper and wide-ranging reasons why physical restraint may be over-used or abused. Mental health care certainly needs a sensible, contextualised and much broader discussion about physical restraint per se, and the reasons behind it’s use and misuse. The ‘face down’ issue is perhaps something of a narrow lens, and when 22% of staff report not having had face-to-face training in the last 12 months, we need to ask why that is.

I have a few observations. Questions about restraint are far from being a solely modern phenomenon, but for those whose 7.5 hour shift seems incomplete without a dose of adrenalin-pumping action and a ‘good decking’, current conditions have never been better.

Beds are disappearing. Only the very sickest of the sick have access to hospital treatment. The most distressed and disturbed are funnelled into smaller and smaller pockets of in-patient chaos, often provided by companies with shareholders and profit margins to maintain and gladly filling the gaps left by the running down of NHS in-patient psychiatry.

I would hope that such critical care would be delivered by the sort of skilled, well trained staff I described earlier. This all too often isn’t the case. Many of our most severely ill patients are being cared for by agency and locum staff with bare minimum training, a lack of experience and often poor communication skills. Many will barely know the names of the people in their temporary care.

This is where the ‘jump on, grab a limb and for f*** sake make sure they’re still breathing’ model of managing potential and actual aggression is practised today much as it was in the dungeons of Bedlam.

Right at this moment, someone, somewhere is in a psychiatric unit posing potential or actual danger to themselves or others. People with mental disorders can and do become violent, and staff are needed to contain the violence and minimise that risk. Hopefully they are with staff who can reassure, listen and diffuse aggression with empathy and skill. They are trained to use restraint safely and appropriately, and to be able to make decisions as to when and how it is used.

Mind’s survey results suggest this is all too often not the case.

Deaf, Daft and Demented: Improving Attitudes to Elderly Care

The woman on the radio sounded distraught. She was calling a phone-in show from the hospital where her frail, elderly Dad was being treated. Treated perhaps, but not being cared for. The caller described a ward full of elderly, infirm patients marooned in their beds trying to reach water jugs across the Grand Canyon of space between them and an impossibly far away bedside cabinet. Others pressed the call button repeatedly for commodes or help with moving up in the bed. Nobody came. 

The presenter Shelagh Fogarty suggested a shortage of staff. Apparently not. The caller described a large group of ward staff lolling around the Nurses Station chatting about Facebook. The phone-in took place on the back of a recent RCN report calling for minimum staff levels on elderly care wards. The RCN survey was itself a response to a catalogue of horror stories surrounding the care of older people. In the same week a Which? Magazine ‘secretshopper’ sting highlighted (yet again) serious failings in domiciliary care. It makes sad if not unfamiliar reading. Missed medication. Missed food and drink. Soiled beds. That sort of thing.

So what are the reasons for this constant torrent of bad news? There are plenty of ‘big picture’ factors involved, and others more eloquent than I have written about some of them elsewhere with the precision of front-line experience. But let’s look at one specific and rather uncomfortable area from my own perspective as a trainer.

It’s one of those elephants in the room that doesn’t get much of a public airing, and goes something like this. 

Care of the elderly is far and away the least popular of the health and social care specialities, and attracts the sort of staff who might just as well be earning a Gold Star for assembling Big Macs.

For as flawed as the bigger picture may be, it is still individual care staff leaving patients to dessicate or care home residents to sit in their own faeces. Whenever I hear one of these reports I imagine myself visited by The Ghost of Christmas Yet to Come, aged by forty years and placed in a nursing home by a family who have ignored my Living Will request to be shot at the merest suggestion of double incontinence. I have a memory span of thirty seconds, and I’m muttering to myself, probably because nobody else will listen. My Inco Pad fills with the end result of my soft diet lunch. A couple of care assistants haul me into a wheelchair and whisk me off to the nearest shower hose, deep in conversation over Kate Middleton’s choice in shoes. 

So in this Dickensian nightmare I’m quite literally at the arse end of the care sector, but back in the real world does it really follow that elderly care attracts the bottom of the pile in terms of it’s staff?

Speaking as a trainer working with hundreds of care staff over the years, most certainly not. But I do often see a demoralised workforce working long hours for poor pay and even poorer conditions. With the best will in the world it’s not hard to see how patients or clients eventually come to be seen not as valued individuals but as names on a job sheet spiralling ever downward  toward ever-increasing neediness and ultimate death.

So what do we do? Do we throw more centralised funding at our local authorities and privatised care providers?  Even if such fanciful thoughts had the slimmest of chances of becoming reality, I suspect this would achieve little in terms of progress beyond a healthier shareholding for their employers.

What about better training for care staff? For as long as I’ve been in the business training has been a luxury expense in an industry long governed by the bottom line of the profit/loss equation. ‘Stack it High, Sell it Cheap’ used to be the mission statement for Tesco but is now the essential business model for elderly care, where training is often seen as a costly irrelevance to short term profit. But could more and better quality training really improve the care and attitudes toward our vulnerable elderly? 
A few years ago I collaborated with some local colleagues on designing and facilitating a BTEC Short Course Award: Caring for the Older Person with Mental Health Problems. It was a fairly simple programme consisting of three classroom-based modules focussed on Dementia, Depression and Challenging Behaviour. We worked with a varied collection of staff from both nursing home, residential and domiciliary settings. Some of our candidates were managers, while most were front-line carers. Almost all were terrified at the prospect of taking a test at the end of each day although Exam Phobia faded quickly once our candidates realised how much they already knew and what they were capable of.

We looked at how depression, so endemically common among older people in care and yet so seldom tackled, can be quite easily identified by care staff using the sort of rapport and person skills that comes inevitably when helping a resident put on their socks every morning.  We looked at magnified images of protein plaques and discussed how these lead to memory loss. We looked at how awareness of the sensory and cognitive deficits of dementia can help us communicate much more effectively and reduce distress. Not only did our candidates earn a recognised qualification but challenged, examined and re-evaluated  how they worked with older people. Now let’s not pretend this was Dead Poets Society but the fact I’m talking about this award it in the past tense irks me more than Robin Williams. And that’s a lot of irk.

We were able to deliver the award only with the help of a generous funding pot from the now defunct Business Link Dorset. Once the funding dried up, so did the course, and we certainly didn’t have the resources to evaluate the shop-floor efficacy of the training. But on anecdotal evidence at least, investment in a reasonably cheap and effective project yielded greatly improved levels of care and support inspired by more positive attitudes and a greatly enhanced sense of self-worth among our groups. With potentially business-ruining CQC reports easily available online and a traditionally high turnover of staff, you don’t really need a degree in health economics to work it out. It’s just good business to have better trained staff.

In the meantime we’ll continue to hear an unending tide of bad news stories and radio phone-ins about staff who have become demoralised and dispirited when they could, with a little time and effort, be taking a fresh look at the work they do as something which is as skilled and satisfying as any of the ‘sexier’ areas of the care and support industry.  

It could certainly beat flipping a burger.

A Longer View of Winterbourne View

Thanks to a few sleepless nights of keyboard bashing and the odd complementary tweet from The Guardian’s @patrickjbutler his employers have kindly (and perhaps unwisely) invited me on to their new Social Care Comment site. Here’s my take on the aftermath of the Winterbourne View scandal.

There have been many initiatives, reports and government level strategies in recent years but few, perhaps none, have hammered at the ramparts of care for learning disabled adults with the force of BBC’s Panorama expose Undercover Care: The Abuse Exposed.
Broadcast on 31 May this year, Twitter exploded almost immediately in response to some of the most unwatchable scenes on television in many years. As the blogosphere and online communities followed not far behind in an eruption of public horror, it was clear that that the care of society’s most vulnerable people had hit a watershed. My own blog posts on the subject and the comments of many both on my own site and countless others made me realise I wasn’t alone in being unable to sleep that night and getting up out of bed to bash seven bells out of my laptop.
But the media bandwagon rolls on and even those most horrified by those scenes are once again tweeting about X-Factor or the bedroom antics of Premiership footballers. Those of us who work in social care might suspect that the status quo has resumed. The sadists within our ranks have resumed their water-boarding, and the senior executives of companies providing care can once again get back to a nice round of golf. So what, if anything, has changed in 133 days?
As a social care training provider my colleagues and I meet hundreds of support staff from local authorities, charities and other care providers up and down the country, and strange as it may seem in the few months since that edition of Panorama I’m left with a glass which is, if not quite half full, is certainly far from empty.
Firstly, we can look to the already well publicised structural changes that have taken place. Both Castlebeck and the Care Quality Commission (CQC) have not just been caught with their trousers down, but suffered the acute embarrassment of being caught in a very intimate moment by an elderly relative popping round for a surprise visit. “Coo-ee, the door was open and… oh dear!”
But my recent experience of running training for care staff perhaps tells us about more than the closure of poor quality homes and a rapid increase in CQC inspections. A public who once knew, saw or heard little about learning disabled people and assumed that it was still the NHS and local authorities providing for them now seems to have woken up to the fact that much of our social care system is now run at a very tidy profit by executives who think more of feeding a racehorse than meeting the needs of a young woman with autism.
Thanks to the Winterbourne View scandal and the subsequent demise of Southern Cross, we now seem now more capable of demanding the sort of excellent, small-scale services where individualised care is more than just an empty mission statement written on a dusty wall plaque. We might even argue that the average man or woman in the street is now much more aware that the care and support for their vulnerable relatives is worth a good deal more than a healthy bottom line, particularly when that comes at the price of shoddy management, poor staffing and a training culture which means little more than the annual fire lecture. 
But no television documentary is ever going to completely rid social care of the occasional rotten apple who, through a combination of individual inadequacy and limp supervision, will quickly go on to sour the rest of the fruit bowl. But we can hope that in the aftermath of Winterbourne View we can all blow the whistle and perhaps get those who could and should have been listening to realise that Panorama wasn’t just a one-off. We’re all watching now.  

Connor Kinsella is an author and training consultant at JCK Training 

Challenging Behaviour: How to Avoid Kicking the Cat

I ran a course yesterday for Residential Care Staff. The imaginatively titled Challenging Behaviour and Dementia course is always interesting in that it reminds me of some of the difficulties care staff have to face, even working with elderly clients. As always, the story of the course is that even little old Doris (85) can and does pack quite a punch when she wants to!

Now according to Google there’s an awful lot of people typing ‘challenging behaviour’ and ‘challenging behaviour definition’ into the little white box, which means if you’re here right now you’re a) writing up a college project or b) working with a bunch of service users/patients/clients who are posing difficulties of one form or another.

Now, I know how it works with students. You just want something quick and dirty to cut and paste into your Word Processor. Yep, been there. So if you just want a definition, here it is. In fact, here’s two!

Definition 1: ‘any behaviour which negatively effects both the ’perpetrator’ and those around them to a significant and/or frequent degree’ (Kinsella 2010)

Definition 2: Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (Emerson 1995)

If that’s fulfilled your essay needs, glad to be of service. Bookmark this page and we may see you again ….

Otherwise, hang on in there.  We’re going to outline some of the key skills we need in dealing with the sort of challenging behaviour which can be problematic, highly unpopular, scary and generally pretty awful, often to the point where we really don’t want to go into work and face another shift. But challenging people with challenging behaviours are no less deserving of our efforts than anyone else, so let’s take a brief look at some of the stuff from the JCK Training Managing Challenging Behaviour course which I hope might be helpful and even save you that extra bottle of wine/shouting at the TV/shouting at family and those occasional feelings of wanting to put our heads through a wall. And of course, we want to avoid kicking the cat. Working with Challenging Behaviour is’nt easy.

The nature of challenging behaviours presented by an elderly care home resident may be very different from those presented by, for example, a young person with borderline personality disorder, but the way we are going to approach the behaviours does not change – we are going to try and replace instinctive, reactionary responses with a more systematic, model-based approach. But first we need a few basic assumptions.
  1. Any service user (or human being for that matter) has the potential to behave in ways which are anti-social, aggressive and likely to have a negative impact on themselves and others. In fact, think of the last time you phoned a call centre. After spending five minutes listening to Greensleeves (no, bloody Greensleeves) interspersed with the patronising grind of ‘your call is important to us but please hang another minute while we make another £4 billion out of your sorry arse’ before eventually getting to speak to a human being called Malcolm, you are probably going to feel like telling Malcolm to shove his headset somewhere dark and possibly a bit damp. See? We can all get a bit challenging sometimes.
  2. The service user is at the heart of our discussion, assessment, planning and evaluation. This may appear to be a statement of the obvious but once a challenging individual has become associated with aggression or worrying behaviour (or put less technically, ‘scared the crap out of us’) that person can easily become marginalised and begins to drift further and further from involvement in their own care. We shall try to avoid this as much as possible although it’s fair to say that some service users will never be able to participate in their own care. In which case a family member or nearest relative  will hopefully be only to glad to be involved. 
  3. It may seem at first glance that a person with severe cognitive impairment caused by dementia or a learning disability behaves in unpredictable, random ways, but all human behaviours occur for a reason and attempting to identify why challenging behaviour occurs is a key aspect of our project.
  4. We are not aiming to ‘cure’ the service user of their challenging behaviour. We are simply aiming to reduce the severity and frequency of the target behaviour so that life is better for the service user and people around them.
  5. Our final assumption is that the advice offered here can offer generic principles of good practice and a guide to using a structured approach. However, there are no magic wands. Local conditions, client characteristics, resources and restrictions will all govern how challenging behaviours are defined and recognised locally, and how we go about managing these behaviours.

The CAPEd (sic) Crusader
In our Challenging Behaviour course we introduce a framework for working with challenging behaviour. Like all frameworks or models we tried to come up with a sexy acronym to help you remember the various bits, but all we could come up with was CAPE

Yes, BANG, WHIZZ or KAPOW might have been more appropriate (and sexy) but the letters didn’t fit. So we have CAPE. So what does CAPE stand for?

  • Clarification
  • Assessment
  • Planning
  • Evaluation

Let’s take  look at these stages and what they mean for us.

We start by asking the question: What is the behaviour? This may at first sight appear a simple and straightforward task, but there are some common pitfalls especially when writing down or recording an incident in a service user’s notes or in untoward incident documentation.  We need to be careful here to actually describe the behaviour, not the emotion behind it. 

Writing ‘he got very angry’ in your notes is a description of how he feels, not of the behaviour itself. Right now we need to simply record what has actually ‘happened’. For those of a grammatical bent, we need ‘verbs’ not ‘adjectives’.
We also need to be aware of the possibility that an incident we are trying to describe may become the subject of further investigation, for example by the police or by a safeguarding vulnerable adults panel, so detail is good. Very good.

A key determining factor in where we go next is whether a behaviour meets a stated definition of challenging behaviour. We have defined challenging behaviour above but of course I’m here and you’re there. Local circumstances and environment will be key in determining what is significant or frequent enough to warrant further assessment and perhaps an action plan.  A person banging their head against a wall or shouting at a support worker will be seen in quite different ways in different environments, which in itself will demand quite different plans and interventions.

The first stage of our framework has asked the ‘What’ question. Our Assessment stage is where we attempt to look at the Who and Why and How questions, so perhaps we are going to get our hands a little ‘dirtier’ in this stage. But the effort expended will be well worth the effort as we attempt to address problem behaviours rather than simply accepting, putting up with or condemning them.

So where do we start? Hopefully with a clear and concise description of an incident or series of events based on our Clarification stage, but remember this is a structured, proactive approach to challenging behaviour and there are some key questions we may wish to ask:
  1. Is there Consensus within a staff team that what has been observed constitutes challenging behaviour according to an agreed definition or baseline?
  2. What is the Frequency of the behaviour? Are we looking at a standalone event or one of a series of incidents?
  3. What is the Impact of the behaviour? Ask the same question of the service user him or herself, and depending on location and circumstances, support staff such as yourselves, family members, neighbours or other.  Or couched in other words, who were the victims of the behaviour and how are they affected?
  4. If a there is a Victim as such including of course, the perpetrator(s), what are their characteristics? This is particularly important if there is a regular pattern to the challenging behaviour.
  5. Is there a Pattern of behaviour? In residential care for example, mealtimes are often a flashpoint for confrontation. Over a longer period of time, seasonal changes may be important or incidents may be seen to occur at a particular time of day.
  6. Is there a Precipitant for a person’s behaviour other than those we have already mentioned? Remember our starting position that behaviour almost never occurs purely at random regardless of the cognitive or functional abilities of the perpetrator. 
  7. Drugs and Alcohol. It may be a question of judgement whether or not we refer to substance use or misuse, but most of us are more than familiar with the association between intoxication and self-destructive or anti-social behaviour.  Our assessment may require more than a simple association between, for example, a client’s habit of drinking a four-pack of nuclear strength lager for brunch and his or her subsequent hostility on home visits, but it is always attempting to assess exactly how and why a substance affects the perpetrators behaviour as opposed to simply stating that ‘they get angry when drunk.’

The above is just a small selection of areas we might want to examine during our assessment, but our most useful tool is our own knowledge and rapport with the people with whom we work, and let us not forget that often the best informant of all is of course the person presenting the challenging behaviour. I often find when running courses that the most obvious question of all hasn’t been asked of the challenging individual: Why do you do it? This isnt always an easy question to ask depending on the individual and the circumstances, but can (if put skilfully and non-judgementally) yield surprising results. 

This is our ‘doing’ or ‘intervention’ stage. Whether we are referring to ‘Action  Plans’, Care Plans’, Support Plans’ or any other terminology which essentially means the same thing, most health and social care organisations have some form of written plan which clearly states what we are hoping to achieve and do with a service user.

We need clear consensus between ourselves as a staff member, our colleagues and collaborators from other agencies (such as professionals from Primary Care Trusts or Social Services or supported housing) as to how we describe challenging behaviours, our assessment and how we are going to respond. If and when appropriate, our planning should include as an essential of best practice a clear collaboration between ourselves and the service user.
Remember one of our initial assumption s from our very first page: we are not attempting to ’cure’ the perpetrator or change his or her personality, but simply reduce the frequency of challenging behaviours, the impact of those behaviours on others and themselves, or preferably both.
By now we have hopefully concluded that a consensual, structured, proactive approach to challenging behaviour is more likely to achieve our outcomes than staff response which is haphazard, reactive and fuelled by panic, fear or resignation. There is always the potential for staff who work regularly with challenging behaviours to become ‘over sensitised’ to verbal or physical aggression, self harm, destruction of property or any other of the challenging behaviours we have identified and set out to manage. 

Evaluation is a means of at least trying to ensure that we see worrying or dangerous behaviour for what it is, and whether we are are constantly evaluating informally over a cup of coffee with colleagues and service users, or more formally through meetings and reviews, our intention is to review the outcomes of our Plan in terms of impact, frequency and quality of life, add to our assessment and look toward the short and long term future which will hopefully mean a much better quality of life for service users, and a less worrying time for your cat. 
Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties Cambridge: Cambridge University Press.

Kinsella, C. (2010) Working with Challenging Behaviour JCK Training

Visit JCK Training for details of health and social care in-house courses, including Working with Challenging Behaviour