Infographic -10 Common Pitfalls Staff Make Clinically Holding People Who Lack Capacity

The team here recently produced an infographic around some of the traps we see staff fall into where they have not had time to consider their approaches.

We have recreated the list here and added some of our suggestions to rectify these common pitfalls.

You can download the original infographic we discuss in this post by following this link.

Legal, Professional & Ethical Considerations

Not ensuring all staff are familiar with the relevant legal and ethical guidelines, such as the Mental Capacity Act (2005) (in England and Wales).

• Regular Training Sessions: Initial training covering the MCA, for example, and then scheduling regular training sessions to keep staff updated and, importantly, checking their understanding of the training and how that affects them in their role.
• Accessible Resources: Provide easily accessible resources, such as handbooks and online modules detailing key legal and ethical considerations in language that reflect the staff team’s abilities to understand complex documents.
• Mentorship Programmes: Establish mentorship programmes where you support individuals (with time & resources) in the organisation who have experience or more in-depth knowledge of the subject to support and guide newer employees in understanding and applying these guidelines.

Capacity & Consent

When assessing a person’s capacity to make treatment or care decisions, not documenting the process and offering a rationale for their decision. Failing to acknowledge that every adult has the right to make their own decisions where possible.

• Comprehensive Documentation: Review the documentation you have in place and currently use and check how clear it is. Can you add simple questions to it as an aide memoir to prompt staff and help them to record relevant information that demonstrates the decision-making process?
• Training on Consent: Provide regular training on the importance of obtaining and documenting consent, but also check for understanding and examples in practice. Move away from tick box training.
• Individualised Assessments: Remind staff to treat each capacity assessment as unique, considering the individual’s specific circumstances and how your organisation prompts the autonomy of the people it supports.

Benefits Vs Risks

When weighing up the benefits and risks of any proposed treatment, going with easy/cheap/historical practice etc., and not considering the urgency and necessity of the procedure. Also forgetting the potential impact on the person’s well-being and if there now exists a less intrusive way to obtain the same goal.

• Multidisciplinary Reviews: Conduct multidisciplinary reviews to ensure all aspects of benefits and risks are considered. Before this, though, you should review both formally and informally in staff teams/meetings regularly and work on building your staff members’ analytical skill muscles.
• Evidence-Based Practice: Encourage the use of current, evidence-based practices rather than historical or convenience-based methods. Staying up-to-date is a professional responsibility, but one your organisation can make easier for its staff. Even senior staff arrive in services with good background knowledge of a topic, but they need to stay aware of the changing foreground knowledge as new procedures/approaches emerge and become the new standard.
• Person-Centred Approach: We say it a lot here, but it is about action and how we work with the people we support. So, we demonstrate ways to prioritise the individual’s well-being and consider less intrusive alternatives where possible should always be the norm, not just in serious medical treatment scenarios.

Staff Training & Competence

Presuming staff training for one context, e.g. violence and aggression, means it is relevant for the delivery of serious medical treatment for individuals lacking capacity. Regular, bespoke training tailored to the scenarios staff may encounter is essential.

• Specialised Training: As a company that specialises in bespoke training and consultancy for clinical treatment scenarios, it’s hard to appear unbiased. However, regardless of your training provider, you need to ensure it is tailored to the specific treatment or procedure. Not all training is equal, especially where the individual lacks capacity.
• Regular Competency Assessments: Implementing opportunities to rehearse scenarios and staff responses allows you to assess staff competency and confidence.
• Scenario-Based Learning: Use scenario-based learning that is controlled but offers real-world, practical, hands-on experience for your staff team.

Policy and Protocol

Not giving consideration to developing and maintaining clear organisational policies and protocols related to essential care and treatment scenarios the organisation encounters.

• Policy Review: Establishing first if any existing policy covers this area of practice in your service. We have worked with several larger organisations to produce a policy after they have embarrassingly realised they have nothing in place to keep everyone safe.
• Clear Documentation: As mentioned earlier, the language of all your documentation for potentially complex areas needs to be easily accessible to all staff. This is especially true considering that for some of the workforce, English may not be a first language.
• Feedback Mechanisms: Implement mechanisms for staff to provide feedback on existing policies and suggest improvements and be part of any review “committee.”

Best Interest Meetings

Holding multidisciplinary best interest meetings and either failing to invite key professionals and family members or failing to reach an agreement, so the outcome is to have yet another meeting due to poor meeting structure & goals.

• Comprehensive Invitations: Ensure all the key professionals and family members are invited to best interest meetings. Consider using scheduling tools such as Calendly or TidyCal to help set a time that is easier and works for everyone.
• Clear Agendas: Develop and distribute clear agendas before meetings to ensure structured discussions and goal-setting.
• Facilitator Training: Ensure whoever is facilitating has the necessary skills to manage the meeting effectively and achieve concrete, measurable outcomes that work for the supported person.

Person-Centred Approaches

Displaying and describing person-centred approaches, such as slogans/posters, but not delivering this to the people they support. We did this for Mr X, so we will do the same for Ms Y.

• Regular Audits: Conduct regular audits to ensure that person-centred approaches are being practised and not just advertised on your organisation’s “glossy brochures” or mission statement plaques in the foyer.
• Individual Care Plans: Has the care plan been developed with the person to meet their individual needs, or is it a rehashed version of one used before for someone else? Sadly, we still come across this in services.
• Feedback Loops: Establish feedback loops with individuals and their families to continuously improve person-centred care and be honest about both what is working and what is not currently.

Positive Behaviour Support & Desensitisation Programmes

Implement positive behaviour support and desensitisation programmes where appropriate. These can help individuals become more comfortable with medical procedures over time, reducing anxiety and resistance.

• Personalised Programmes: Develop personalised programmes for the supported person, which may mean the assistance and support of specialist input for both PBS and especially desensitisation programmes.
• Training for Staff: Provide training for staff on how to implement and support these interventions effectively. Hopefully this will be delivered by the professionals responsible for the programme.
• Regular Updates: Regularly update these programmes based on the person’s progress and changing needs. Ask as a team as well as the person themselves where possible if you can see progress. Are you making things better for the supported person?

Premedication

When using premedication to help manage anxiety and discomfort, not advocating for the doctor to consider the person’s history and tolerance levels compared to someone that is medication-naïve.

• Detailed Medical Histories: Ensure that detailed medical histories, including medication tolerance, are readily available for doctors. Sometimes, however, in busy environments/appointments, they do not consider that the standard test for the vast majority of the population may be significantly difficult for the supported person and your staff team to complete.
• Advocacy Training: Train staff to advocate effectively for the individuals in their care regarding premedication. This starts with making staff aware of the benefits of the use of pre-meds and what will help the Doctor when considering a prescription.
• Collaborative Planning: Encourage collaborative planning between doctors, staff, and family members to determine the most appropriate premedication strategy. We still encounter situations where a person with a long history of large doses of antipsychotic or neuroleptic medication use is prescribed an inappropriately small dose of premedication.

Post Procedure Support & Review

Failing to plan what the emotional support offered to a person may look like and how best to offer this during the planning stages leading up to the procedure.

• Care Planning includes Support & Follow-up: Develop comprehensive support plans outlining emotional support before, during, and after procedures, which may lead to our next point of training.
• Training in Emotional Support: We should not assume all staff are able and competent to offer emotional support effectively, especially to team members. Remember, trauma-informed approaches include everyone in the service, not just the service users.
• Follow-Up Check-Ins: Schedule regular follow-up check-ins post-procedure to monitor emotional well-being and adjust support as needed. This includes all staff involved regardless of seniority as research is showing they are just as susceptible to trauma in care settings.

Long-Term Planning

Failing to consider the long-term plan if the person should need the same procedure/investigation/test in the future.

• Holistic Assessments: Conducting a more holistic assessment that considers not just the immediate medical needs but also the long-term implications for the individual’s health and well-being.
• Contingency Plans: Establish contingency plans for unexpected changes in the individual’s health status, ensuring swift and appropriate responses that have potentially emerged as things to do or not to do.
• Continuity of Care: Promoting continuity of care by maintaining detailed records and involving the same staff in future procedures where possible and if appropriate, as well as being able to pass on relevant, helpful information to other services/professionals if the supported person moves on to elsewhere.

What have we missed?

You can download the original infographic we’ve discussed in this post by following this link.

Let us know if you feel we have left any out or if you think we have missed something here. Alternatively, if you need any support, consultancy or training, then please get in touch on the links below 👇👇