Guidance moves away from the use of physical restraint

The use of restrictive interventions in mental health nursing is a regrettable part of the job, but when violence and aggression occur, nurses must act.

The use of restrictive interventions in mental health nursing is a regrettable part of the job, but when violence and aggression occur, nurses must act.

However, the focus should be on anticipating and reducing risk to prevent a service user’s agitation or anger spiralling, according to a new guideline from the National Institute for Health and Care Excellence (NICE). That way, use of restrictive interventions is less likely.

Figures produced by NICE show that there were 68,683 assaults reported against NHS staff in England between 2013 and 2014; more than two thirds (69%) of which occurred in mental health or learning disability settings.


The guideline, Violence and Aggression: Short-term Management in Mental Health, Health and Community Settings, places greater emphasis on de-escalation and gives a broad description of what de-escalation might look like.

In a bid to avoid or minimise restrictive practices, it sets out relevant training in psychosocial methods for staff in different settings, including skills to assess the range of factors that can contribute to the likelihood of behaviour becoming violent or aggressive and how to defuse aggression when it arises.


Other recommendations in the best practice document, which updates all areas of the previous 2005 guideline, suggest a framework for inpatient psychiatric wards.

This should include ensuring service users are offered appropriate psychological therapies, physical activities and leisure pursuits and support for communication difficulties, recognising how a service user’s mental health problem might affect their behaviour and how restricting their liberty and freedom of movement can be a trigger.

The guideline covers adults, young people and children with a mental health problem within mental health, health and community settings.

Advance decisions

While the guideline now places a stronger focus on anticipating and reducing the risk of violence and aggression, manual restraint – including face down or ‘prone’ restraint – is included alongside other restrictive interventions. It states that staff should encourage service users to make advance decisions or advanced statements on the use of restrictive interventions.

The guidance stresses that a restrictive intervention should only be used where de-escalation and other preventive strategies, including medication, have failed and there is a risk of harm to the service user or others if no action is taken, and then the ‘least restrictive option’ should be used to meet the need.

It states that staff should:

  • Not routinely use manual restraint for more than ten minutes.
  • Avoid taking the service user to the floor, but if needed, the supine (face up) position should be used if possible.
  • Only use the prone (face-down) position for ‘as short a time as possible’.
  • Not use manual restraint in any way that interferes with the service user’s airway, breathing or circulation, or affects their ability to communicate.

One of the most vocal campaigners against use of face-down restraint is mental health charity Mind. In a report published in 2013, Mind obtained data from mental health trusts in England under the Freedom of Information Act which showed nearly 40,000 incidents of physical restraint by one or more members of staff in 2011-2012. Of these, more than 3,000 were in the ‘dangerous’ face-down position.

The report warned: ‘Face-down restraint, which means pinning someone face down on the floor, is dangerous and can be life-threatening. It can feel like you’re being suffocated and can cause even more distress.’

It called on the government to end the use of face-down physical restraint in all healthcare settings and include it on the list of ‘never events’.

Restrictive practice

Against the backdrop of this report and investigations into the abuses revealed in 2011 at the now closed Winterbourne View private hospital, the Department of Health (DH) published a report into restrictive practice in 2014.

Citing evidence that restrictive interventions had not always been used only as a last resort, then care and support minister Norman Lamb said in the foreword that restrictive interventions ‘have been used too much, for too long and we must change this’. Staff needed to be given the skills to do things differently, he wrote.

The guidance did make clear that restrictive interventions ‘may be required in life-threatening situations to protect both people who use services and staff or as part of an agreed care plan’, he noted.

But a chief action point said: ‘Staff must not deliberately restrain people in a way that impacts on their airway, breathing or circulation, such as face down on any surface, not just on the floor.’ This was interpreted by many as heeding Mind’s call.


The guideline seems to have taken a more pragmatic approach. Len Bowers, who has a strong track record in researching violence on wards and sat on the NICE guideline development group, says there was not sufficient evidence to rule out face-down restraint.

‘All restraint is dangerous and therefore all restraint should be avoided where possible, which is why the emphasis is on de-escalation and other preventative strategies,’ says the professor of psychiatric nursing at the Institute of Psychiatry, Psychology and Neuroscience.

‘However, the NICE guideline group did not believe that the balance of risks and the evidence was so clear that face-down restraint could always be avoided in all circumstances, given the variety in which human beings come, in terms of height and strength, and the varieties in which nursing staff and the available people to restrain, come.

‘I would add to that it says clearly in the guideline that rapid tranquilisation is also dangerous and adds to the risk.’

RCN professional lead for mental health Ian Hulatt says the guidance that came out in 2014 was in the context of then minister Norman Lamb wanting to ban restraint, particularly face down, and also the Mind report which expressed real concern.


‘Since then I would imagine there has been increased discussion and debate within the profession, not just in mental health settings. The fact is that sometimes face down occurs and it occurs because that person has gone down to the floor in that posture and may remain for a brief moment until staff place them in a safer position,’ Mr Hulatt says.

‘To never use it has been argued to be impossible, and that’s why NICE has been a little bit more flexible and pragmatic.’

A DH spokesperson said its guidance was to ‘promote a culture where the use of all forcible interventions is radically reduced and staff and patients are treated with dignity and respect. That’s why we launched a two-year programme, Positive and Safe, which encourages organisations to explore alternative techniques and approaches while ensuring staff are adequately trained and supported in these.

Exceptional circumstances

‘The programme makes clear that use of physical restraint should only happen in the most exceptional circumstances and following any incident staff should reflect as a team to see if anything could be done to prevent similar incidents.’

The aims of the government guidance and the NICE guideline show how thinking has moved on, says Mr Hulatt, namely moving away from restraint to a more preventative and therapeutic approach.

‘Awareness that this is something that should be done very much as a last resort and that there are things that can be done before is a welcome development,’ he adds.


Mind has welcomed the updated guideline, notably its emphasis on service users’ rights, the framework for anticipating and reducing violence, guidance to reduce the use of restrictive interventions, and a ‘clear direction’ not to use manual restraint in a way that obstructs airway, breathing or circulation or the ability to communicate.

Mind senior policy and campaigns officer Alison Cobb said: ‘We would have preferred the NICE guideline to have been stronger on not holding people face down. But, if all the positive recommendations in the guideline are followed, it will be much less likely that situations get to this point.’

Updates on the original (2005) guideline
  • Identification of potentially violent and aggressive service users and the evaluation of methods and tools for prediction and risk assessment
  • De-escalation methods and short-term psychosocial intervention methods
  • Seclusion
  • Physical restraint (includes a new ten-minute limit on the routine use of manual restraint)
  • Pharmacological interventions
  • Training or education requirements for the above-mentioned interventions
  • Mechanical restraint (for example, with adults used only in high secure settings, except when transferring service users between medium- and high-secure settings. Not used at all with children)
  • Anticipation of violence and aggression
  • Environmental influences and how to modify them
  • The role of advance directives in the management of violence and aggression
  • Widens scope to include secondary mental health care, community health care, primary care, social care and care provided in people’s homes.
  • Includes children and young people
More information

Violence and Aggression: Short-term Management in Mental Health, Health and Community Settings

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