BILD Code of Practice for Minimising the Use of Restrictive Physical Interventions: Planning, Developing and Delivering Training

Citation

Roy Deveau (2016), "BILD Code of Practice for Minimising the Use of Restrictive Physical Interventions: Planning, Developing and Delivering Training", Tizard Learning Disability Review, Vol. 21 No. 3, pp. 165-167. https://doi.org/10.1108/TLDR-12-2014-0041

The “fundamental purpose” of this fourth edition of the Code of Practice (the Code) “is to help bring consistency to the development and delivery of training courses and to the governance, policies and procedures of the organisations where the training courses are delivered” (p. 14).

The Code is structured to reflect advances in BILD’s thinking, especially the belief that “whole organisation approaches to supporting individuals whose behaviour is described as challenging offer the greatest likelihood of good outcomes for them” (p. 13). There are three sections, sandwiched between an Introduction and a Glossary. The three sections are aimed at the three main audiences for the Code: section 1 for purchasing organisations (comprising 14 pages); section 2 for training organisations (comprising 24 pages); and section 3 for individual trainers (comprising 5 pages). The Code intends to provide “good practical advice” and guidance for all stakeholders regarding the “development and delivery of restraint reduction training that includes training in physical skills” (p. 10). The Introduction provides a useful guide to recent developments in thinking and practice about the management of those service user behaviours perceived as challenging. For trainers and training organisations holding or seeking BILD accreditation, the Code describes things that “must” be done. Since accreditation is not in place for training purchasers, the Code’s more general rubric is to “urge” or “recommend” rather than require.

The most prescriptive section (section 3 for individual trainers) outlines how to prepare, deliver and record training provided and monitor the conduct of attendees. For example, trainers must risk assess the training environment to be free from hazards, introduce themselves “each morning”, report specified categories of “inappropriate conduct” of learners, be able to provide first aid, keep professional records and have adequate professional indemnity insurance. Individual trainers must have the required qualifications and review their ability to “deliver training that addresses”, e.g. primary and secondary prevention strategies, risk assessment, legislation, behaviour assessment and support plans, in a service context of positive behaviour support (PBS) and “functional assessment” of the behaviours of people using the services of the purchasing organisation.

The least prescriptive section (section 1 for purchasing organisations) describes BILD’s view of “appropriate contexts” for provision of BILD accredited training. A substantial body of research, policy and campaign material has been directed to describing what appropriate contexts should look like. This complex background is mainly provided in section 1. For example, subsections cover: providing a framework for PBS and minimising the use of restrictive practices; organisational policies and procedures; best interests; risk assessment and health and safety; course curriculum; development and continuous review of the quality, effectiveness and relevance of training. In essence, purchasers, trainers and providers are told that reduced reliance upon more restrictive physical interventions (RPI) will require their use only in the last resort, their application on a gradient of forcefulness, their risk assessment and their being carried out only with consent or after a best interests process. Further, staff training should be based on a training needs assessment informed by a behavioural audit of the challenges they face, all PI use should be monitored and there should be good communication with service users and families.

Some recommendations may have a significant impact upon the context for people who may present behaviour described as challenging. For example, it is urged that the inclusion of physical skills in training should be agreed at the most senior management level and a named manager (with relevant skills and knowledge) be made responsible for collating and using information on RPI use and behavioural audit, including where information on “critical incidents” goes and is used.

Section 2 describes what BILD accredited training organisations must and should provide. Training organisations must provide a specified “core theoretical content”, e.g. populations, legislation and guidance, proactive and positive support of behaviour, post incident management and debrief, de-escalation and reactive behaviour management strategies. Training must be delivered to meet the needs described in the service’s behavioural audit and risk assessment, and training needs analysis, which training organisations should be prepared to advise purchasers upon if required. A prescribed “values base” for training includes a human rights perspective, keeping people safe and treating them with compassion. The delivery of training and monitoring of outcomes are described in great detail including: number of trainers to participants; recording, testing and reporting of participants’ progress; health evaluation of participants; provision of mats for floor techniques; and the written agreement between purchaser and training organisation. PBS and functional analysis appear to be required as part of the service context prior to training. Particular attention is given to training in the “physical techniques” especially “floor restraints” which must only be used when all other less restrictive alternatives have been tried and found to be ineffective. Training organisations also have significant responsibilities for monitoring the work of trainers and ensuring their skills are up to date.

A central part of section 2 is an in-depth description of the training to be delivered by BILD accredited organisations. This includes the useful guidance that de-escalation skills must be taught, that only physical interventions appropriate to the assessed needs of individuals living in the services where the staff being trained work should be taught, and clear guidance on avoiding the use of pain based or floor based restraints. The latter may be a challenge for some training organisations and services. The emphasis on RPI reduction plans as an integral part of any training where RPIs are taught is useful. Training organisations “must only” provide training to organisations that have suitable policies and the training curriculum provided is expected to be designed based upon training needs assessment, behavioural audit and risk assessments for individuals.

The Code, like other expert guidance/policy, seeks to promote evidence-based staff practice. This presents some difficulties, as many of the practices prescribed have rather limited evidence bases. The very business of providing staff with discrete training, including in physical interventions, is itself not well supported by evidence (Allen, 2001). Other important practices recommended by the Code, e.g. de-escalation and debriefing, also have limited research support (Deveau and Leitch, 2015; Inglis and Clifton, 2013).

The writers of the Code are, no doubt, aware of these limitations and attempt to address them through their commitment to whole organisational approaches, which are supported by significant research. However, by according equal importance to all individual elements, the Code perhaps risks lessening the development of good practice in organisations as they seek to “tick” all the boxes; rather, it may be more beneficial for organisations to consider, in depth, which elements may best suit their services’ unique environments and support the development of the leadership necessary, at all levels, for successful implementation of change.

Despite these misgivings, the Code is required reading for trainers and training organisations providing management of challenging behaviour training and can be recommended for senior managers in organisations. It is also likely to be useful for many others, especially individuals advocating for improvements in the lives of people living in staffed services.