Restraint: Taking the Heat out of Challenging Behaviour?: the resilience of older people in residential settings

Older people can so quickly find that negative labels are pinned on them.  They are labelled as exhibiting challenging behaviour, defined in my terms as shouting, abusive language, and sometimes unnatural physical strength.  In the majority of people these behaviours are known as anger and aggression but in residential settings everything ordinary changes as a medical approach takes over.   Residential settings provide an environment where every day seems the same, where people cannot remember the day, the date and time, where activity is inactivity, where there is nothing in common with the strangers sitting either side and the staff supporting them are strangers; where the television blasts out its repetitive messages displaying indecipherable pictures, where a radio pumps out songs with no distinguishable words, often competing with the television clangour at the same time.   It seems that coming from the outside into this environment and atmosphere where ‘one size fits all,’ older people display amazing resilience with the ability to survive in this bizarre and bewildering artificial world.

So am I being over the top, who am I to say how it is? 

First of all I have first-hand lived experience, not just of one setting but of many.  Secondly, I am privileged to have the professional position to visit a wide variety of residential settings where similar situations are witnessed over and over again.  Put twenty to thirty people in a multi-purpose room, create all of what has been described above, and you are transported into a very depressing and overwhelming environment.  Add to this experience overpowering heating levels where to feel fresh air on ones’ face is a rare or non-existent occurrence.   It is not difficult to restrain people.  Turn up the heat on people who have lived long and who have reached a point in life where losses experienced are multiplied several times over and often occur simultaneously, drown out the sadness with a cacophony of sound and the one thing in your control is to exert ‘challenging behaviour,’ or fall asleep.  Add to this a time in life where the bladder weakens, more toilet visits are required and while there is a desperate need for a second cup of tea, and where the fear is that even one cup of tea will demand a trip to the toilet the result is that each day is spent in constant worry.  The concern is that an accident is likely to occur and one will be labelled ‘demanding,’ ‘selfish,’ inconsiderate of others and to ring that bell for help is one ring too many.   

If you feel the scene is too unbearable, maybe it is because you have been in that difficult position yourself or have spent time agonising over finding a setting for a relative or friend.  It can be an agony or it can be a relief when you find a setting that ticks most of the boxes..  Whatever the emotions, it is not you that will live in that setting.  There are instances where relatives or guardians weald the ultimate power of denying a resident any outside contact.  And this is their home!

Restraint is often applied when it is deemed a person will get up from their armchair unaided or want to wander outside.  Let me pause a moment.  How often do you get up out of bed or from a chair without thinking, arrange to do things outside the home, visit friends, see a film?   The thought of being restrained, conforming to a timetable that never varies, having to ask people for help whose names  cannot always be remembered, especially when people are engaged for a day from an agency, it would make anybody want to give up the fight.  The more so with a lack of continence support, a lack of refreshment when one feels like it, and the constant blare of television and radio and people trying to make themselves heard and understood.

‘Restraint,’ ever a threat but more a reality.   ‘Challenging behaviour’ – bring it on!

Ann Macfarlane

Always looking for the positives. 

PS: There are occasions where residential settings provide quality services, where older people are treated with respect and dignity, are listened to and requests acted upon, but the bar has to be raised.  I am the first to acknowledge where I see good practices and a willingness to learn.

PPS:  Visiting a friend in hospital yesterday, a patient got out of the armchair.  ‘Oh, I’m stiff, I’ve sat too long.’

Nurse: ’ Sit down, don’t wander off.’

Patient:  ‘It’s good to stretch one’s legs, take exercise, I was just going to look out of the window.’

Nurse:  ‘Sit down, I need to see where you are.  Don’t move.’