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How do we move away from restrictive practice?

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Restraining a resistant child for a non-urgent procedure. Is it best to just ‘get it done’ or is it an infringement of a child’s rights?

Despite many children having positive experiences of potentially painful procedures, many also report feeling ‘left out’ of communication with health professionals and not really knowing what is going on. Children can become upset and resist procedures either verbally or behaviourally expressing “Stop”, “I am scared”, “No” or “I don’t want this”. What happens when we are faced with a child who is resistant and upset? And how do we adequately prepare them for what is going to happen and include them in their care?

When attempts to distract and cajole a child do not work, professionals and parents can revert to take the Nike approach and ‘just do it’”. Focusing on completing the procedure may be at the detriment of a child’s short and long-term psychological and emotional well-being. Many grown-ups can remember when, as a child, they were ‘pinned down’ for a procedure, and they live with procedural anxiety as a result. Surely things have improved and the days of ‘bruticaine’ are behind us? Unfortunately, there continue to be reports of and evidence that too often children are held against their will for non-urgent procedures to be completed.

Although no one starts a procedure with the aim of restraining a child, it can be difficult to judge when a firm cuddle or hug from a parent to help their nervous child, becomes a forceful hold with a child saying, “Please stop” and the adults reassuring them that “It is nearly done”. It can be hard to ‘step back’ and pause a procedure, especially when a procedure is nearly done. A mindset of “it will only take another second” is often at odds with how long it will actually take to complete. It’s difficult to admit if a procedure has not gone well and a child has been held against their will whilst upset, so this is rarely openly acknowledged and documented. The child is told “well done”, given a sticker and everyone is relieved to leave the room/space.

Is it in the best interests of a child to ‘get it done quickly’ so they are upset for a shorter amount of time and staff can move on to treat other patients or is holding a child against their will when they are crying “stop, stop” an infringement of their rights? These are some of the questions a new standards document aims to help consider.

What are the ‘rights-based standards for children undergoing procedures’?

The ‘rights-based standards’ aim to ensure that the short and long-term physical, emotional and psychological well-being of children (aged 0-18 years) are of central importance in any decision-making for procedural practice. The standards consist of seven core rights-based principles to support health professionals in advocating for children’s rights and positive procedural experiences.

The standards propose an approach to minimise the anxiety, distress and harm which can be experienced by children whilst they are undergoing a clinical procedure. The standards define and promote supportive holding as an approach to prioritise children’s rights and well-being and challenge the use of restraining holds for non-urgent clinical procedures, whether intended or labelled as such, by raising awareness that such holds can be harmful and their use should be minimised, openly acknowledged and documented. We need to talk about restraint in an open and honest way!

The standards define supportive holding and restraint as:

“A supportive hold involves supporting a child to feel calm, secure and settled during a procedure. In a supportive hold a child agrees to the procedure and positioning and/or does not express signs of refusal. Supportive holding is a way of providing comfort to the child and helping them to maintain a good position for the procedure”.

“A restraining hold is any action to prevent a child moving freely against their choice or will. Regardless of who holds a child, if it is against their will (expressed verbally and/or behaviourally) the hold is a restraining hold. A restraining hold should be recognised as such and not labelled as a clinical, supportive or comfort hold”.

Who developed the standards?

These standards have been developed by an international collaborative multi-disciplinary group called iSupport, consisting of over 50 members from around the world (UK, Ireland, Jordan, Indonesia, Cambodia, South Africa, Sweden, Australia, New Zealand, Brazil, Canada, USA, Spain, Netherlands, Malawi and Korea). The group has consulted extensively with youth and parent forums and professional organisations. The challenging conversations and consultations between different perspectives led to the broad principles in the standards being developed. There are versions of the standards for health professionals, one for children and parents and a simple preparation sheet to help children plan for their procedure, have a say on what matters to them and get involved in making choices.

Why should the rights-based standards be used?

The rights-based aim to ensure that a child’s best interests are prioritised in all decisions and actions before, during and after a procedure and their interests should be prioritised over those of their parents, professionals and the institution.  Most importantly the standards aim to prompt an open and honest conversation between professionals about accepted procedural practice and whether a child’s best interests are served by ‘getting it done quickly’.

The standards aim to challenge many of the assumptions, unwritten rules and dogma which can underpin procedural practice.

  • That a procedure is a success if it has been completed, regardless of whether a child has been upset, distressed or held against their will.
  • That children, particularly younger children will not remember so it is best to just ‘get it done’.
  • That a child will just get more upset if a procedure is stopped and re-scheduled or paused and tried again in a minute.
  • That if a parent is using a tight hold to keep their child still and stop them wriggling away against resistance, it is not restraint.
  • That using the term clinical holding covers all kinds of holding for procedures and that it is not important to document or openly acknowledge that restraint was used and the rationale for its use.

Future goals

The ‘rights-based standards for children undergoing clinical procedures’ are currently open for consultation – please click on the links to share your views from the UK or Australia, or on the translated documents and survey for Spain and Brazil. Moving forward, the ISupport team will be developing some training resources for health professionals and families to align with the key principles of the standards. We will also be developing an implementation framework to enable the monitoring and generation of evidence around the use of the standards in practice. 

This blog has been written by the international ISupport team.

About the authors

  • iSUPPORT: International collaborative standards to SUpport Paediatric Patients during clinical prOcedures, Reducing harm and establishing Trust are a group of over 50 health professionals, academics, young people, parents, child rights specialists, psychologists and youth workers from around the world (UK, Ireland, Jordan, Indonesia, Cambodia, South Africa, Sweden, Australia, New Zealand, Brazil, Canada, USA, Spain, Netherlands, Malawi and Korea).

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