The purpose of this book is to provide a practical framework for organisations to “[…] identify and review what is happening within their services but also to actively reduce reliance on restrictive practices at an individual and systemic level” (p. 8). The practical framework builds upon related BILD Publications, including a code of practice for the use of physical interventions and ethical or practical approaches to reducing their use. The writing of the book was supported by a Florence Nightingale scholarship and influenced by a working visit to Australia.
Of the book's content, 51 of the 91 pages comprise a series of 17 checklists. The checklists and associated action plans are offered as a menu from which organisations may choose those relevant to their particular context.
The checklists are preceded by four chapters containing brief summaries of significant issues underpinning the framework. Chapter 1 (The meaning, use and impact of restrictive practices) (RP) defines a wide range of practices as restrictive, including mechanical, chemical and environmental restraints, whilst pointing to physical interventions (PI) as the predominant RP. A distinction is drawn between proactive, purposefully planned RP and reactive RP. The former appear to be regarded as acceptable whilst reactive RP, i.e. emergency last resort interventions aimed at immediate management of risk are not. The implication that RP is acceptable when used in a proactive or planned way is worth debating. A list of legislation for the four UK countries is useful. Chapter 1 describes RP as a Human Rights issue and promotes Positive Behaviour Support (PBS) as the main evidence based model for preventing use of RP.
Chapter 2 (Risk and restrictive practices) focuses in depth upon PI and risk factors associated with individuals subject to PI and particular PI techniques. The absence of any description of the risks associated with other forms of RP described in Chapter 1 is notable.
Chapter 3 reviews Individual and Chapter 4 Organisational factors in reducing RP. Individual factors considered in Chapter 3 include, for example, sections on: preventive and proactive approaches, functional assessment and PBS, individualised support, good physical and mental health care, positive lifestyles, and involving family and friends. These headings are briefly outlined often using bullet pointed information.
Chapter 4 is based upon two frequently cited lists of organisational factors involved in successful RP reduction strategies and include, for example, leadership, data use to inform practice, user participation and staff training/development, effective de-brief for staff and policy development. The author adds other factors viewed as important to reducing RP, e.g. promoting holistic approaches, clear governance and accountability, appropriate legislation and a human rights approach.
The 17 checklists have accompanying “action plans”. Each action plan describes a series of tasks suggested to meet the checklist. Those using the framework complete the plan by describing actions needed by whom, when these will be done by, and the outcome. Checklists/action plans include, for example, proactive risk assessment, skills development and employment, increasing positive lifestyle outcomes, promoting good physical and mental health and establishing a leadership team. These checklists and action plans offer a comprehensive, perhaps too comprehensive, structure for providing good quality support.
The aim of this book, to reduce RP, is something very few would disagree with. However, significant weaknesses may limit its potential to do so.
First, the focus upon a “planning” framework. Focussing upon rational planning processes to achieve change whilst neglecting issues of “relationships” was also evident in a closely related BILD Publication by Allen (2011) reviewed in Deveau (2012). For example, the checklist “Use of debrief as a learning tool” focuses upon implementing policies and procedures. However, it is likely that the nature of the relationships between managers and frontline staff will be the most important variable influencing the impact of debriefing.
Second, potential readers focused upon improving practice may be put off by the predominance of well meaning, value laden generalisations that present little in the way of substance to achieving laudable goals. This could be likened to the cookbook recommending a “lovely, crispy, rich topping” without specifying ingredients or cooking instructions needed to achieve this. For example, the action plan “promoting holistic approaches” includes the task to “develop approaches that support the implementation of the mission statements and values of the organization” but this could be enhanced with information or examples of implementation.
Third, the book has an uneven balance between different areas that perhaps reflect particular interests. For example, discussion of the potential benefits of the Australian legislative approach, in comparison to the UK, does not clearly relate to the book's aim. Although, the Care Quality Commission's (2009) regulatory standard 7H that services have “Identified and documented in a plan that sets out preferred measures to prevent and minimise the use of restraint, which is reviewed as the person's needs change” appears to meet the author's suggestion for a UK “explicit requirement to ensure that there is a plan to reduce reliance upon restrictive approaches” (p. 28). Implementation of legal structures is likely of greater importance than the nature of the structure. The detailed focus upon the risks of PI and lack of attention to risks of other RP (e.g. medication) could be usefully addressed.
In conclusion, organisations are rightly responding to the aftermath of abuse at Winterbourne View and providing services of good quality is supported by deciding upon a focus for change. This book may provide such a focus. However, other resources are available and provide additional on-going evaluation and incentives to support implementation and improvement. An obvious example is CQC standards and inspection. In addition the recently launched Driving Up Quality Code (2013), employing self assessment and the setting of improvement goals, is reinforced by public acknowledgement and commitment through adoption of the code with annual self-assessment and improvement plans made publicly available. The Driving Up Quality Code provides useful practice examples and guidance on “what good looks like”. This Code may have significant impact having Government endorsement and intended recognition by service commissioners and CQC inspectors. Whilst checklists and action plans may be helpful, improving organisational performance requires clear expectations, transparent assessment and recognition of current performance and incentives to change.
