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Measuring Competence in Physical Restraint Skills in Residential Child Care - Research Findings

DescriptionStudy aimed to design and test measuring instruments which could be used to assess the competence of trainees and practitioners in their use of three specific physical restraint techniques.
ISBN
Official Print Publication Date
Website Publication DateDecember 24, 1998


Social Work Research Findings No. 21
Measuring Competence in Physical Restraint Skills in Residential Child Care

Lorna Bell and Cameron Stark

Contents


Main Findings
Introduction and Context
Acquiring and retaining skills
The therapeutic crisis intervention programme
Designing the measuring instrument
Testing the measuring instrument
Consistency among trainers
Complexity of restraint skills
Implications of findings
Using the measuring instruments
Further Information

This study aimed to design and test measuring instruments which could be used to assess the competence of trainees and practitioners in their use of three specific physical restraint techniques: the team restraint; the single person restraint; and the basket hold. The study focused on these techniques, developed by Cornell University in its Therapeutic Crisis Intervention (TCI) programme, because they were being taught to residential child care staff throughout the United Kingdom.

The expertise of thirteen TCI trainers was used to develop the measuring instruments. To test the instruments videos were made of trainees practising the restraint techniques and a comparison was made of the thirteen trainers' assessments of the trainees when they did not use the instruments with their assessments when they did use the instruments.

Main Findings
  • There was a wide variation among trainers when they relied on their own expertise to assess the competence of trainees. This suggests that trainers do not agree on what is acceptable and unacceptable practice. There is therefore a need for further work in this area to clarify for practitioners, trainers and managers what are the acceptable and unacceptable aspects of performance of restraint techniques.
  • There was greater consistency among trainers when they used the measuring instruments to assess the competence of trainees. However since the study involved a small number of participants it is not possible to determine whether or not the improvement was statistically significant.
  • Two new assessors achieved greater agreement than could be expected by chance when assessing the competence of trainees, though the level of agreement was not as high as expected. However systematic differences found between assessors' scores suggest that agreement could be increased by joint training sessions for assessors.
  • The restraint techniques are very complex and occur in a short space of time and are therefore very difficult to learn and assess. The use of videos in training and assessment would assist in assessing the competence of trainees.
  • The measuring instruments could be used by trainers and trainees in their present form as a useful checklist of what is required in performing the restraint techniques. However they would need to be modified further before being used as a measuring tool for accreditation purposes.

Introduction and context

Children in residential care can exhibit disturbed and violent behaviour which can result in them being aggressive to themselves and to others. Over many years practitioners, managers and policy-makers have tried to find ways of dealing with children whose behaviour is dangerous with a range of interventions such as crisis intervention and crisis de-escalation, as well as the use of sanctions such as restricting leisure activities and control of pocket money. There has also been some debate about the use of physical restraint by residential child care staff when the child or those around him or her need to be protected from the child's aggression without hurting or humiliating the child.

A number of training programmes have been developed in recent years to train staff in the use of physical restraint. Although some of the content of these programmes have been evaluated there has been no evaluation of how well trainees learn physical restraint skills and whether they are able to retain that learning over a period of time.

Acquiring and retaining skills

While there has been limited research conducted into the acquisition and retention of physical restraint skills there have been a number of studies in the training of other complex skills such as in the training of mouth-to-mouth resuscitation and the firing of tank guns in the military. These studies suggest that learning a complex skill is difficult and that even when trainees acquire competence in the skill at the end of training there is a significant loss in skill when they are re-tested at periods, sometimes as short as two weeks, after the training. These studies also suggest that skills acquisition and retention can be improved if trainees: are over-trained; are taught only one skill at a time; are systematically assessed and given feedback during training; and attend regular refresher training sessions.

The therapeutic crisis intervention programme

The Therapeutic Crisis Intervention programme (TCI) was selected as the subject for this study because it was one form of physical restraint training being introduced in Scotland and England and it was being used by a number of agencies, both statutory and voluntary, to provide training for their residential child care staff. The TCI programme was developed in the 1980's by Cornell University as a package that could be taught by agencies' own trainers who had previously attended a Cornell TCI "Train the Trainers" programme. The TCI programme includes training in crisis intervention, crisis de-escalation and post-crisis intervention as well as training in restraint techniques. The focus of this study was on how these techniques could be measured and not on the effectiveness of the techniques.

Designing the measuring instrument

At the beginning of this study there was no systematic way of assessing whether or not trainees on the TCI programme had learned the skills they were taught or whether or not they were able to practice the skills competently. In order to achieve this a measuring instrument for each of the three techniques needed to be designed which could then be used to assess the performance of trainees. To design the instruments thirteen experienced TCI trainers in England and Scotland were recruited. They were sent forms to complete in which, for each technique, they had to identify, a) the stages of the restraint, b) all possible errors that could be made in each stage and c) the rating they would give to each error, i.e. mild, moderate, severe or unacceptable. These responses were collated and the collated responses sent back to the trainers asking them to re-consider their initial responses in the light of the feedback from their colleagues. This process was continued until there was a high level of agreement between the trainers and this occurred after three rounds. The measuring instrument for each technique was produced by making a list of the agreed errors and giving each error its agreed rating. The ratings were assigned a score of mild = 5, moderate = 10, severe = 15 and unacceptable = 20. A trainee was deemed to have failed in the performance of the technique if he or she scored 15 or more.

Testing the measuring instrument

Before the measuring instruments were designed video-tapes were made of ten trainees each performing each of the three restraint techniques. The thirteen trainers were asked to use their expertise to assess the performance of the trainees. This provided baseline data on the consistency of trainers' assessments. After the measuring instruments were designed the trainers were asked use the measuring instruments to assess the performance of the trainees. This provided data on the consistency among trainers when they used the measuring instruments and therefore provided some indication of the reliability of the instruments. Videos were made of approximately 80 scenarios of trainees performing each restraint ( a total of 240 scenarios) and two assessors, who were not trainers in TCI, then assessed the performance of the trainees in all the scenarios so that the inter-rater reliability of the instruments could be determined.

Consistency among trainers

Findings from the study suggest that there is a large variation among trainers when they use their expertise to assess the performance of trainees. In some instances the performance of trainees was evaluated as excellent by some trainers and very poor by others. When the trainers used the measuring instruments there was greater consistency in their assessments but there was still a significant degree of variation. When the two new assessors evaluated the performance of the trainees they achieved a level of agreement that was greater than would be predicted by chance. Thus the measuring instruments are successful in improving the reliability of assessments though because of the small numbers involved it is not possible to say that the improvements are statistically significant. However there is still room for improvement and the instruments need further modification before they can be used as accurate measures .

Complexity of restraint skills

This study found that the TCI restraint techniques involve a series of complex actions and are more complicated to execute than the mouth-to-mouth resuscitation skills. For example, the team restraint involves two restrainers, moving their bodies, legs and arms at the same time and in a co-ordinated manner in a period of sixteen seconds. It was possible to make 44 errors during this manoeuvre. This means that the restraint techniques are very difficult to learn, especially when three techniques are taught at the same time. Furthermore, because the restraints are quick and complex, it is difficult for trainers to observe and assess the competence of trainees execution of them as they occur. Video-taping trainees seems the only possible means for evaluating trainees.

Implications of findings

This study suggests that improvements could be made in the training of trainers and in training practitioners in restraint skills.

The finding that there was considerable variation among trainers is particularly important in relation to the legal situation. Experienced trainers are sometimes used as expert witnesses to advise the court as to whether certain aspects of physical restraint are acceptable or unacceptable.

The apparent lack of consistency in trainers might be improved by:

  • providing more in-depth training of the techniques to trainers;
  • assessing and certificating trainers
  • organising regular refresher training; re-assessment and re-certification of trainers.

Research into the training of resuscitation skills has also identified ways of improving the acquisition and retention of skills which could be adopted by trainers in physical restraint skills. These include:

  • training only one technique at a time;
  • allowing sufficient time during training for trainees to learn technique to saturation level;
  • holding regular refresher training for practitioners;
  • assessing and certificating the competence of practitioners;
  • using video-recording of trainees as part of the training and as a means of assessing competence.

Using the measuring instruments

In their present form the measuring instruments could be used as a checklist of errors so that trainers, trainees and practitioners could systematically review the performance of restraint skills. However the instruments will need to be modified further before they can provide a sufficiently accurate measuring tool for accreditation purposes. In particular, the number of errors needs to be reduced so that only those errors which could cause injury or prohibit the satisfactory completion of restraint are included.

Further Information

The study was carried out by researchers from Stirling University and Ayrshire and Arran Health Board. It was funded by the Social Work Services Group and The Scottish Office.

'Measuring Competence in Physical Restraint Skills in Residential Child Care' the research report summarised in this Research Findings, may be purchased (price £5 per copy).

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