Millfields Charter

The Millfields Charter is an electronic charter which attempts to call for an increase in calls for a ban on the teaching to frontline staff of all prone (face down) restraint holds. It was founded by individuals who have links to organisations which provide training to care environments.

Background

The use of physical interventions in care environments is a controversial subject. The debate in the UK and the US about the safety of physical restraint procedures in care environments is more prominent. The prevention of behavioural difficulties, often by environmentalenrichment and person centred approaches, are becoming part of the ‘zeitgeist’. The Millfields Charter calls for a ban on the use of ‘dehumanising’ strategies such as physical restraint and specifically prone restraint. The arguments involve both scientific and moral aspects.

Preventing and reducing physical restraint usage in care environments.

Physical restraint does not occur in a vacuum. Whilst relatively little is known about the use of physical restraint in care environments; it is generally accepted that restraint methods should be viewed as a ‘last resort’.

The role of environmental factors in the maintenance of challenging behaviours.

Preventing physical restraint usage not only requires staff training programmes in safe usage of methods; but also the development of organisational cultures which actively discourage usage of these methods. Reducing overcrowding and adopting person centred approaches which examine the causes and functions of challenging behaviours and their remediation, are becoming increasingly more commonplace. In some cases restraint usage can exacerbate distress among individuals who may be experiencing post traumatic stress (See Pitonyak, 2004 for examples). Restraint in this context can be construed as a failure of communication between service users and their carers.

Training staff in physical restraint methods: The evidence.

Despite the importance of the debate, there appears to be little hard evidence for the effectiveness and safety of different methods of restraint. The evidence for training staff in these methods is considered to be at best crude (Allen 2000)^[1], with evaluation of training programmes being the exception rather than the rule (Beech & Leather, 2006)^[2]. Despite these limitations, vast numbers of care staff are trained in so called ‘physical interventions’ including physical restraint, with the difficulty that the skills taught begin to decay as soon as the person leaves the training room. In addition, although many staff are taught these methods, in some cases they rarely employ them in practice. It is accepted that staff training in physical interventions can increase carer confidence, but, is that sufficient justification for the general implementation of such training? The limited evidence of staff training has long been regarded with some degree of scepticism. Cullen (1992)^[3] maintained that staff training was necessary but not sufficient on its own for behavioural change to occur. In sum, we have a large number of untested training systems routinely in use in care environments. It would appear to be sensible to reduce the numbers of staff who receive such training and to exclude physical methods which may be implicated as ‘high risk’. In the absence of hard empirical evidence, what measures can be adopted to limit the use of physical interventions in care environments?

Restraint Related Deaths

Whilst not the only reason to justify the limitation of restraint techniques, restraint related deaths can inform us about extreme uses of methods. This is analogous to air accident investigators examining rare accidents to help reduce their likelihood of re-occurring in the future. A survey in the US in 1998 reported an estimated 150 restraint related deaths in care environments (Weiss, 1998). Low frequency fatalities appear to occur with some degree of regularity. Nunno, Holden & Tollar, (2006)^[4] investigated 45 restraint related deaths in US childcare settings. 28 of these deaths were reported to have occurred in the prone position. In the UK restraint related deaths would appear to be reported less often. It is unknown what the true levels of restraint related deaths are. However, two prominent deaths in the UK have further focussed the debate. David ‘Rocky Bennett’ was an adult black male experiencing extreme distress in a secure psychiatric facility in the UK. He was restrained for over 20 minutes in the prone position and died. See Positional asphyxia

What does the Charter say?

"We the undersigned are increasingly concerned by approaches used across care and 
education settings to control people and manage aggression.
 
We believe many of the techniques deemed as appropriate are dehumanising, 
dangerous, abusive and detrimental to the relationships between staff in 
care settings and those for whom they care.
Many staff attending such courses even appear to be injured whilst training and 
yet such training is accepted in many parts of the health, social care and education 
system as appropriate for use with people who need our services. People who use the 
services are rarely given a choice about this.
We demand a change in the care of people with mental health problems or 
learning disabilities, who can be treated in dehumanising and degrading ways.
We deplore prone physical restraint!
We believe there are alternatives, which enhance the quality of life and improve 
standards for individuals and their carers. Such methods maintain the relationship 
between staff caring and users of services, and reduce incidents of violence.
It's time for a change, to put care back into caring settings.
It is our firmly held belief that the use of the following physical interventions 
should cease immediately and be replaced by more sensitive techniques and better 
education for all staff.
•       Methods using restraint in the prone / face down position which are dangerous 
        to physical health and are degrading 
•       Mechanical restraints, which tie, strap or in other ways prevent movement 
•       Methods which cause pain and involve locks to joints 
•       Methods which do not involve user or advocate choice 
•       Methods which cause fear and increase anxiety 
Do you agree?"

The Charter does not just focus on one issue. Clear in these statements is a moral framework.

Criticism

The charter has stimulated a debate in the UK. McDonnell (2007) ^[5] in a debate article, highlighted the arguments in favour of the Charter. McDonnell focussed on the limitations of restraint usage and the lack of effectiveness data. He maintained that staff training programmes which focus on restraint are a by product of a fear industry which often depicts staff training as a solution to the problem. Restricting the teaching of physical interventions and the banning of prone methods was proposed as a way forward. He argued that a ‘paradigm shift’ is required in the training industry to change the attitude to behaviour management training. Paterson (2007)^[6], while supporting the motives of the Charter signatories, disagreed with the impact of their proposals. He argued that there are a variety of prone holds, some of which use more force than others. He also argues that the scientific evidence for the relative effectiveness of specific restraint methods is limited and therefore banning prone holds would constitute a large scale uncontrolled experiment.

Research on the effects of restraint position does not support the view that prone (face down) restraint has harmful effects. Measurement of lung function in various restraint positions has demonstrated that restraint face down in a flat position, with no weight applied by restraining persons, has no significant effect on breathing^[7].

Leadbetter (2007)^[8], presented a balanced response to the first two authors (McDonnell, 2007^[9]; Paterson, 2007)^[10]. Leadbetter (2007) applauded both authors for encouraging debate on this topic. With regard to the issue of prone restraint he argued that ‘we are well beyond any creditable debate that restraint in the prone position is safe’. However, he stopped short of agreeing to a generalised ban arguing that sectors such as mental health may require the limited use of such methods, whereas intellectual disability services might achieve such a goal.

In conclusion, encouraging debate would appear to be an important focus of the Millfields Charter. A focus on prevention of restraint usage, the restricted use of methods such as prone holds and the encouragement of a clear moral framework for the use of such methods. The Charter obviously has proponents and opponents who are equally passionate about their views. The debate about restricting behaviour management practices is obviously wider than the issue of one class of restraint methods. The Charter appears to have stimulated a useful and important debate.

Useful links

For information on regulation of physical interventions we recommend the British Institute of Learning Disabilities website

For person centred approaches to behaviour management the website of David Pitonyak.

The coalition against institutionalized child abuse website contains information on restraint related deaths in young people.

There are many training systems in this field to date only two have publicly supported the Charter. These are, Studio3 Training Systems and PROACTSCIPrUK.

The Millfieldscharter

References

1. ^ Allen, D. (2000b). Training carers in physical interventions: Research towards evidence based practice. Kidderminster: British Institute of learning Disabilities.
2. ^ Beech, B & Leather, P. (2006). Workplace violence in the healthcare sector: A review of staff training and integration of training models. Aggression and Violent Behavior, 11, 27-43.
3. ^ Cullen, C. (1992). Staff training and management for intellectual disability services. International Review of Research in Mental Retardation. 18, 225-245.
4. ^ Nunno, M., Holden, M., & Tollar, A. (2006). Learning from Tragedy: A survey of child and adolescent restraint facilities. Child Abuse & Neglect: The International Journal. 30, 1333-1342.
5. ^ McDonnell, A.A. (2007). Why I am in favour of the millfields charter. Learning Disability Practice, 10, 26-29.
6. ^ Paterson, B. (2007). Millfields charter: drawing the wrong conclusions. Learning Disability Practice, 10, 30-33.
7. ^ Parkes, J. & Carson, R. (2008) ‘Sudden Death During Restraint: Effect of Restraint Positions on Lung Function.’ Medicine, Science and the Law 48(2) 137-41
8. ^ Leadbetter, D. (2007).Millfields charter: finding the middle ground. Learning Disability Practice, 10, 34-37.
9. ^ McDonnell, A.A. (2007). Why I am in favour of the millfields charter. Learning Disability Practice, 10, 26-29.
10. ^ Paterson, B. (2007). Millfields charter: drawing the wrong conclusions. Learning Disability Practice, 10, 30-33.