Here are a few of the questions we get asked
- ARFID – Avoidant / Restrictive Food Disorder: A condition characterised by an eating or feeding disturbance leading to nutritional deficiency, weight loss, or interference with social functioning, often linked to sensory sensitivities or past negative experiences with food.
- Anxiolysis: A medical treatment aimed at reducing anxiety, often using mild sedatives to help a person remain calm during medical procedures without inducing full sedation.
- Best Interest Meeting: A meeting held to determine the most appropriate course of action for a person who lacks capacity to consent to treatment, ensuring their needs and rights are considered.
- CANH – Clinically Assisted Nutrition and Hydration: Medical treatments used to provide nutrition and fluids to individuals who are unable (sometimes unwilling) to eat or drink by themselves, often delivered via a tube inserted into the stomach or veins.
- Capacity & Consent: The ability of an individual to understand, retain, weigh up, and communicate decisions regarding their healthcare, including blood tests.
- Clinical Holding: A form of restrictive intervention where staff hold a person to allow a medical procedure, such as a blood test, to be carried out safely – See our other page https://www.clinical-holding.com/what-is-clinical-holding/
- Court of Protection: A court that makes decisions for people who lack the capacity to make decisions themselves.
- De-sensitisation Programme: A structured approach to gradually reduce anxiety and fear of needles through exposure and behavioural strategies.
- Nasal MAD – Nasal Mucosal Atomising Device: A device used to deliver medications like Dexmedetomidine or Midazolam into the nose and absorbed through the nasal mucosa, providing a non-invasive method of sedation or anxiolysis.
- Needle Phobia: A severe fear of needles, often diagnosed according to the International Classification of Diseases (ICD-11) or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
- Person-Centred Approach: A method of care that focuses on involving the individual in all aspects of their treatment, prioritising their preferences, comfort, and dignity.
- PBS – Positive Behaviour Support: A strategy that aims to improve quality of life and reduce challenging behaviours through understanding the individual’s needs and preferences.
- Premedication: The use of medication to reduce anxiety, pain, or agitation before a procedure such as blood taking.
- Restrictive Interventions: Actions that restrict an individual’s freedom of movement or autonomy, including physical restraint, sedation, or the use of mechanical devices.
- Trauma-Informed Approach: A framework that recognises the impact of past trauma on individuals and seeks to minimise re-traumatisation during medical procedures.
- Venepuncture: The process of obtaining a blood sample from a vein, typically using a needle.
Clinical holding is typically a planned restrictive practice that allows staff to deliver serious medical treatment, essential care practices, or access routine treatments previously denied due to their inability to comply with the requests of practitioners.
It can be seen as a continuum of interventions from verbal instruction and hand-holding through to the application of restrictive practices such as physical, mechanical or pharmacological interventions.
We have answered this question more fully in one of our posts so check out
What is Clinical Holding – A Definition
This depends on lots of factors, not least where the person lives. In England, where we are based, the Mental Capacity Act 2005 provides the legal framework for situations where an adult may lack the capacity to consent to treatment or care.
At Clinical Care Holding, we support staff in various countries, so occasionally, we will need to rely on specialist legal advice. The legal authority and ethical questions are answered by the patient, their family/advocate, and usually a multidisciplinary team—we may be part of those discussions, but those decisions have to be made by others.
We will only deliver training in any restrictive approaches after these other professionals connected with the patient’s care and support have answered all of the legal and ethical questions.
Before any restrictive practices are taught, the minimum we feel is acceptable currently, even for what may be seen by some as not even restriction, is at least three hours of theory in non-restrictive approaches first.
- This would include
- Legal & Ethical Considerations
- Supporting People in Decision Making
- Risks / Benefits of Clinical Holding & Other Restrictive Approaches
- Policy / Procedures to support practice
- Post Procedure Support, Review, Documentation & Recording
However, all our training is bespoke for each individual; we do not support a “sheep dip” approach, so this varies depending upon the proposed essential care or treatment.
Take a look at one of our downloads Topics that Should be Considered for Inclusion in Clinical Holding Training Sessions, for more insight on what we think should be included.
Our staff, having worked in healthcare, education, and social care supporting children and adults with intellectual disabilities, are strong proponents of person-centred thinking and doing. Part of our values includes working with a person-centred mindset and seeing the patient as the best authority on themselves as the starting point. This is at the core of what we do, in addition to our values towards trauma-informed approaches.
In addition to our extensive experience supporting individuals with intellectual disabilities across different settings and keeping the person’s views uppermost, we actively collaborate with those they see as important around them, such as family, friends, significant others, advocates, etc.
We steer families and staff teams to adopt this mindset and look to include or create additional approaches, such as visual schedules and social stories tailored to the unique needs of the person before any medical procedure during our consultancy.
Exposing the person to excessive distress or continuing with the treatment where the risks appear to be escalating must be avoided at all costs. To reduce the likelihood of this, our consultancy and/or training sessions with staff address both of these.
We do this by working with the person and everyone involved to formulate an intervention or treatment plan.
That would include some of the following elements;
- Clear Criteria for the Intervention
- This would outline specific conditions under which the procedure must be stopped, which would include signs relevant to the person of physical harm or psychological distress.
- Continuous Monitoring and Review
- Throughout the procedure/treatment, we advocate, wherever possible, for one person (separate from the procedure) to continuously monitor and review events as they happen. This is in addition to the responsibility all practitioners involved share. You can read more about this Critical Ally Model, which we have adapted, on the Foundation of Nursing (FONS) website here.
- Use of Clear Stop Criteria & Signal
- This is exhaustively discussed and agreed upon during the Best Interest meeting and planning stages, so everyone is aware of it.
- Escalation Sign & De-escalation Procedures
- It is important that practitioners will be able to spot any changes in the person early on and then know which person-centred strategies are likely to work best.
- Training & Simulation
- Simply put, the opportunity for some staff to just stop and consider the treatment plan and their intended role in it, can make a significant impact on the success of essential treatment or clinical diagnostic scenarios for some busy staff teams.
- We monitor and control our sessions to include the following four essential processes.
- Training to provide the foundational knowledge
- Rehearsals so staff are pre-planning for the actual event
- Practice to hone specific physical techniques and skills (if taught)
- Simulations that are controlled to be immersive, real-world scenario experiences
- Debrief and Review Process
- This helps safeguard the person in several ways, including
- Staff Accountability following up to see if the established protocols, policies and training were followed or if there were any deviations.
- Person-Centred Planning – Feedback from the person who experienced the procedure, their loved ones and advocates are all incorporated into the debrief. This can directly inform how to better prioritise their preferences and minimise distress going forward.
- Evaluating Decision-Making to determine if the process was robust. Additionally, clarifying whether the professionals involved felt their actions were justified and whether the decision to stop the procedure in response to distress was made appropriately and efficiently.
- This helps safeguard the person in several ways, including
Do your strategies involve the use of non-restrictive approaches such as positive behaviour support?
We are committed to pursuing non-restrictive approaches, which can sometimes be achieved solely by adopting positive behaviour support approaches.
We have staff members who have worked as part of community-based behavioural support teams.
All our training includes non-restrictive approaches first and the use of other strategies such as PBS and desensitisation programmes for example.
Sadly, we have had experiences of some opposition to this approach from a couple of organisations who just want “some physical skills”.
Globally, there is no doubt that patients will, at times, need to remain completely still for treatment/care/investigations to take place. Consider right now how many patients worldwide are anesthetised, for example, which is the most restrictive strategy available.
We try to help with solutions to fill the void between the patient who is able to comply with the treatment without any intervention through to the appropriate use and need for a general anaesthetic. We also support some anaesthetic teams to make induction/recovery a less traumatic event for the person.
However, there are obvious risks with any restrictive intervention – chemical, physical, environmental or mechanical.
Some of these potential risks include
- Physical and psychological trauma and distress
- Possibility of reinforcing negative perceptions of health and social care staff, which can adversely impact therapeutic relationships
- It may negatively impact upon the patient’s willingness to accept future treatment
- Potential liability issues for healthcare and social care providers who cannot demonstrate training and intervention plans to reduce such risks
Some of the potential benefits, however, include
- It may prevent serious health consequences or risk to life if the clinical intervention is urgently needed
- Allows for the necessary medical treatment or procedures to be provided when the person lacks capacity to consent and it is in their best interests
- Safeguards the person’s health and well-being if treatment will provide significant therapeutic benefit
- Is a last resort when all other less restrictive alternatives have been ineffective or ruled out
- The temporary use of a restrictive practice that is planned and staff have had training for may be better than permanent consequences of declining health or poorer quality of life
Our consulting and training revolve around supporting people to make clear, defendable decisions that reflect our caring values and all current best practices worldwide. We help you consider the risks and outline a clear treatment plan to reduce the likelihood of them occurring.
At Clinical Care Holding, we are there to support you along that journey in more of a supportive ongoing relationship rather than a one-off event (although occasionally, that is what is required).
Getting the post-procedure plan in place ready after considered input and planning is where we can help you. In some healthcare settings, this is part of the discharge planning following admission to an acute service.
Making post-procedure planning equally as important as the treatment plan itself is key to this.
When it is first identified that the patient may need treatment, investigations, or care and is potentially unable to give informed consent, clinicians should consider both short-term and long-term implications. This may mean, on balance, currently, no treatment will be offered on the balance of benefit vs. risks.
Where the likelihood of longer-term or repeat treatment for the patient are a possibility it is essential this if factored straight away into the plans and that both immediate and ongoing post-procedure support is available.
Robust post-procedure review and debriefing.
It may be helpful to consider two areas of focus for clinicians and families during the post-procedure phase. Simply, these can be viewed as
- The legal, professional and organisational recording and reporting of the procedure
- The emotional well-being of all those concerned
The service’s existing documentation process will lead the recording, reporting, and organisational learning process. We have some examples on the website of what should specifically be recorded if any form of restrictive intervention has been used. Obvious questions would also include whether the treatment plan worked, whether it was followed, and what changes for the future may be necessary.
The other strand of post-procedure review is more focused on the psychological well-being of the patient and everyone else involved.
Opportunities and approaches that work best for the patient should have been discussed in the very earliest meetings to discuss the treatment options. The most suitable professionals, surroundings, structure, and approaches should have been agreed upon.
Equally, staff also need time for their own personal reflection and professional development, reviewing their thoughts on the procedure. There are many varied ways staff can do this. Some prompt questions staff could use can be found in a reflective practice prompt aide here. After all, the vast majority of staff in caring settings do not enter the job to engage in restrictive practices such as clinical care holding, and this should not be forgotten.
