We at NFPS have recently received requests for ‘risk assessments’ of our advanced restraint techniques. Interestingly, it is something we have rarely been asked for historically, and for good reasons, as shall be revealed within this article.
The requests have originated from those delivering training within Health and Social Care and is being largely driven by the Client of the NFPS trainers’ mistaken belief that it is mandatory to obtain a certain Certified training to continue to operate. As part of obtaining this Certification, the physical intervention system being utilised must be accompanied by documented risk assessments for all its restraint techniques.
Given it is foreseeable that other NFPS family members will be faced with this request, we felt it prudent to produce this article so that they, and indeed anyone, will be in a better position to respond to such a misinformed request.
Whilst I am the lead author, Jim Snipe, Gary Ross, Alex Hunter, Doug Melia and Trevel Henry have also contributed to this article. We hope you find it helpful when addressing this topic and when dealing with Senior Management.
Position Statement
NFPS believe it is not feasible to produce a single, competent, and all-encompassing written risk assessment for physical restraint techniques due to the numerous dynamic, situational, and individual-specific factors that influence risk in both training and operational environments. What is feasible is ‘risk management’, which relies on real-time dynamic assessment, staff training, and procedural safeguards.
‘Risk Assessment’ v ‘Risk Management’ In The Context Of Applying Physical Restraint Techniques
Risk Assessment (RA):
A structured process of identifying, analysing, and evaluating potential hazards, threats, and risks associated with the application of physical restraint techniques to another human being. It requires quantifiable, and predictable conditions from which the likelihood and severity of harm to the individual being restrained, the staff applying the restraint and to those directly and indirectly affected during the application of physical restraint(s) can be measured.
Risk Management (RM):
A dynamic, continuous process that involves implementing cogent strategies, controls, and measures to mitigate or eliminate risks identified during the risk assessment phase. This includes but not limited to: utilising the most appropriate restraint techniques; continuous monitoring during application; adapting techniques and practices; effective communication; de-escalation at earliest opportunity; taking all reasonable and necessary steps to safeguarding the welfare all concerned real-time; ensuring compliance with legal and ethical standards; providing suitable staff training; and reviewing incidents to improve future practices.
The Nature Of Physical Restraint And Its Inherent Risks
Physical restraint inherently carries risks and these risks include, but are not limited to, the following:
Medical trauma:
Redness, skin tears, abrasions (especially with the elderly population), bruising, fractures, or asphyxiation due to improper positioning (poor technique) or underlying medical conditions.
Psychological trauma:
Anxiety, PTSD, or other mental health consequences due to perceived or actual use of force. Noteworthy here is the published paper, by Tania D Strout, that covers this subject impressively. Thanks Jim!
Environmental hazards:
Slips, trips, and falls, which may result from obstacles, wet floors including bodily fluids, uneven floors or confined spaces.
Unpredictable responses:
Variability in individual reactions due to pain tolerance, emotional state, or pre-existing conditions.
Because these factors vary on a case-by-case basis, it is not possible to predefine a universal risk profile for any given restraint technique.
The Requirement for Dynamic Risk Assessment (DRA) During Physical Restraint
A competent risk assessment requires identification of hazards, affected parties, likelihood of harm, control measures, and severity assessment. However, in the context of physical restraint, these factors are constantly changing and cannot be accurately captured in a static document. Instead, a DRA must be conducted in real-time, considering, but not limited to:
Individual-specific (Personal) risk factors:
Age, weight, medical conditions, past trauma, substance use, mental health status, disabilities including neurodivergence.
Situational factors:
Number of staff involved, subject resistance, presence of weapons, and escalation of force.
Environmental conditions:
Space constraints, obstacles, temperature, lighting and surface traction.
A written risk assessment cannot account for all these factors in advance; instead, staff must be trained to assess and respond to risks dynamically.
Legal and Operational Considerations Associated With RA & RM
A legally robust approach to restraint risk management involves:
Use of the least intrusive and least restrictive alternative:
Restraint should only be used as a last resort, when all de-escalation methods have failed, or honestly perceived as highly-likely to fail.
Competency-based staff training:
Ensuring personnel can recognise risk factors and adapt restraint techniques accordingly.
Ongoing risk awareness and monitoring:
Continuous assessment before, during, and after restraint to minimise harm: ensure duty of care is adequately maintained.
Post-incident review procedures:
Identifying risks that were realised and improving protocols based on real-world experiences.
From a legal standpoint, attempting to create a definitive written risk assessment for restraint techniques could create false assurances or liability issues if unanticipated circumstances arise; especially if these circumstances were reasonably foreseeable by a suitably competent person in the field. It is worth mentioning at this stage that you can risk assess for extreme circumstances, but you cannot risk assess for exceptional ones.
Actuarial Risk Assessment and Structured Professional Judgement (SPJ)
“Actuarial assessment tools are commonly used. However, they have serious limitations, including emphasis on static risk factors, a lack of emphasis on risk management, poor generalisability, and the use of a mechanistic process that disengages the practitioner from the client, and eliminates relevant knowledge and expertise in reaching a judgement (Department of Health, 2007; Douglas and Kropp, 2002). Furthermore, they lack specificity in the individual case and fail to provide any predictive validity beyond a group average (Cooke, 2010; Hart, Cooke and Michie, 2007). (Managing Clinical Risk: Logan and Johnstone, 2013)
“… part of the problem of ‘objective’, actuarial risk assessment is that it does not take account of the context and applies a rational model to risk, which assumes that both the service user concerned and the individuals working with them will be inclined to act rationally or predictably. Risk is not an objective enterprise”. (Assessing Risk, A Relational Approach: Blumenthal, Wood and Williams, 2018)
The SPJ approach reflects a conceptual shift away from predicting dangerousness to managing risk. It is an evidenced-based approach to risk assessment (Hart and Logan, 2011). SPJ retains the strengths of both the clinical and actuarial approaches in that it is grounded in empirical research but, crucially, it allows the clinician to exercise discretion and professional judgement. The reliability and validity of this approach is well established (Douglas, et al., 2013). This approach requires the assessor to follow a series of stages to ensure a systematic, robust and individualised evaluation of a persons’ level and nature of risk. Central to the SPJ paradigm is decision theory”. (Managing Clinical Risk: Logan and Johnstone, 2013)
The “clinician” in this context would be the person executing a restraint technique in a given set of circumstances. The SPJ paradigm (decision theory) possesses similar elements to the more familiar ‘National Decision Making Model’ (NDMM), which all restraint practitioners should be familiar with.
So, now we have robustly established that no such risk assessment of restraint techniques exists or could possibly exist, the insistence on one is not only misguided but also dangerously misleading. It creates, in many, a state of confusion and false belief that such a document can be constructed and should exist. Any effort to satisfy such a document may give rise to false assurances and in any case ignores the fundamental reality that competent restraint risk assessment and management relies on real-time, informed decision-making by trained professionals, not a generic, one-size-fits-all document and should never be treated as a ‘tick-box’ exercise.
To persist with this question in light of these facts is either an act of wilful ignorance or professional incompetence. Which one is it?
The Distinction Between Medical Review and Medical Risk Assessment
A medical review of a restraint technique may outline potential anatomical, physiological and psychological impacts (hazards) when executed in a competent manner. However, a medical risk assessment requires measuring likelihood and severity of injury across varying scenarios, which is impractical because:
Severity cannot be universally quantified:
Different individuals have different thresholds for injury and psychological trauma.
Multiple variables affect medical outcomes:
Strength of application, subject resistance, underlying conditions, situational and environmental hazards all alter risk.
Unpredictable medical complications:
Restraint-related deaths have been linked to conditions like Excited Delirium or Acute Behavioural Disturbance (ABD), metabolic disorders, cardiovascular complications, COPD, asthma, emphysema, positional asphyxia, drug ingestion (prescribed and recreational); which cannot be predicted accurately in advance.
These are just some of the considerations which form part of a medical risk assessment and as such, medical input should focus on risk awareness and harm minimisation rather than attempting an absolute risk quantification.
A particular and important point to discuss here is Excited Delirium or ABD. Gary Ross and Jim Snipe correctly highlight that there should be a range of conditions that would have specific risks attached, and some are already mentioned above but especially with regards to ABD.
Gary goes on to say:
“The problem with ABD in a Healthcare context in the UK, and specifically within Mental Health settings, is that they refuse to acknowledge its existence, which could cause difficulties.
“What is definitely needed, and this is where effective training programmes come in, is an explanation of how ABD presents and manifests, so those tasked with managing individuals suffering from this issue recognise it early.”
“This approach has been acknowledged by medical specialists from both ‘ED’ and ‘Resus’ within Kings College Hospital as having saved numerous lives.”
Holistic Risk Assessment of Restraint Techniques
A truly ‘holistic’ approach to restraint risk assessment would necessitate accounting for all physical, psychological, environmental, ethical, and legal variables simultaneously. However, as outlined throughout this article and the following headings, the inherent unpredictability of restraint situations makes this an unattainable goal:
Unpredictability of Human Response:
A holistic approach assumes a comprehensive understanding of how individuals will react, but individual variability in physical and psychological responses makes this impossible.
Environmental and Situational Complexity:
Restraint situations occur in uncontrolled settings, where even minor changes (e.g., floor surface, bystander involvement) can drastically alter risk levels.
Ethical and Legal Constraints:
Ethical frameworks such as deontology (duty-based ethics) and utilitarianism (outcome-based ethics) conflict when applied to restraint. A deontological perspective would argue that certain restraints should never be used due to their potential to cause harm. A utilitarian view might justify restraint if it prevents greater harm to the individual or others.
The challenge is that risk assessments attempt to provide a definitive framework, yet ethical decisions in restraint scenarios remain highly context dependent.
While guidance exists, laws and human rights principles introduce a level of ambiguity and subjectivity that prevents risk assessments from being exhaustive or universally applicable. These legal and ethical constraints surrounding physical restraint highlight the impossibility of a holistic risk assessment.
Medical Uncertainty:
The impossibility of knowing every individual’s medical history or predisposition as applied to restraint-related harm undermines any holistic predictive model.
Doug Melia carried out surface level research of the word ‘holistic’: it means “whole”, “complete” or “entire.” It was first introduced into modern usage in 1926 by Jan Smuts, who coined the term “holism” in his 1926 book, Holism and Evolution, where he described it as the principle that “the whole is greater than the sum of its parts.”
Smuts’ concept was rooted in systems thinking, emphasising that living organisms, societies, and even knowledge should be understood as interconnected wholes rather than as isolated parts.
The term holistic has been widely applied in fields including medicine, education, psychology, and risk assessment, always referring to a whole-system approach that considers all influencing factors rather than just isolated elements.
So, considering the many personal impact variables of who is being held and by whom, and the accompanying environmental and situational impact variables particular to that set of circumstances, how would this work to risk assess a single physical restraint technique?
Within the Certifying Organisations’ ‘Standards’, it is written:
“Training providers must ensure that each physical restraint technique that is included in the curriculum is holistically risk assessed.
The risk assessment must include:
- trainability, complexity, effectiveness, and fragility of the technique
- risk factors to people including moving/manual handling risks physical/physiological risks, psychological risks (risk of causing or retriggering trauma) and risks to dignity”
Doug has correctly asked this Organisation who are requesting these holistically approached Risk Assessments the following: “Please point me to a method of how to do a ‘Holistic Risk Assessment’ of a particular technique?”
Further, Doug proclaims to have asked experts from the CQC and the HSE to corroborate their stance on this and states that they are of a similar feeling to himself; that there are medical reviews and risk assessment for hazards, but not physical restraints.
It is claimed that the whole final risk assessment must be independently reviewed by an external person with significant experience of providing training in restrictive practices for the population the restraint is intended for use with.
As Jim Snipe correctly points out: “How many people who complete the final risk assessment have the required experience in these sectors?”.
Further, Jim humorously proposes, as Jim does, that we need to design an ‘effectiveness meter’ with a built-in fragility scale to address the Holistic Risk Assessments’ requirement for “effectiveness and fragility of the technique”.
As part of Doug’s communications with the Certifying Organisation setting these ‘Standards’, he was pointed towards Standard 1.3.4. Here it contains: “a bit more detail about how to contextualise risk assessments to individual service populations”, as stated by a representative from this Organisation.
The issue with the eight criteria mentioned is that it is arguably forcing the trainer to produce a document of ‘absolutes’; and as stated, creates false assurances and potential liabilities to the person offering this as a competent Risk Assessment.
Let’s look, briefly, at some of these criteria based on the exact wording of Standard 1.3.4. I have substituted numbers in place of bullet listings; however, the ordering is accurate:
“The Risk Assessment for each physical restraint must record any potential of risk in the following areas:
- psychological or emotional harm…
- Risks to dignity…”
As intimated previously, how is one meant to accurately assess how someone will be psychologically or emotionally affected by the application of a physical restraint, even if there is ‘trauma informed’ input, especially before factoring in the plethora of circumstances in which the restraint may need to be applied? Likewise, how does one measure accurately the impact to a persons’ dignity, especially in the context of preventing greater harm and saving life?
Doug’s request is a reasonable one in that it is essentially asking the Certifying Organisations who set these ‘Standards’ to provide a comprehensive example of how to meet the Standard. I was encouraged to see, in parts at least, that it appears to require input from both staff and service user perspectives, as staff are arguably neglected on many occasions when discussing physical restraints and sacrificed at the altar of service user welfare (there, I said it!).
Staff perspective certainly applies when looking at:
- “trainability and complexity of the technique…
- the fragility of the technique…”
These criteria are alarming to me for they intimate that the Organisation may accept techniques, or rather ‘sign-off’ providers which utilise techniques which are inherently complex in nature and difficult to learn. Anyone who has trained with NFPS knows how egregious such techniques are, including from a Legal and Health and Safety perspective.
Further, it is required to assess the fragility, which is the increased risk to safety associated with the failure to execute the technique with absolute precision. Arguably, failure of any technique increases risk to the safety of all concerned, however, you cannot accurately quantify this nor assign absolute outcomes. This is also why the NFPS system has been robustly pressure-tested, adapted and evolved to meet the operational requirements across multiple sectors, in real-life situations; otherwise, what is the point in learning techniques that will fail when called upon to potentially save life?
The other four criteria are equally open to scrutiny, however numbers 6 and 7 must be mentioned here for they make specific mention of the risks to breathing and circulation. This is strikingly alarming on the basis it intimates, at least to me, they may accept techniques which knowingly impair breathing and circulation as part of a restraint system; and that is also egregious and a violation of Human Rights.
The reason I state this is that nowhere in this Standard does it say that any technique known to increase risk to breathing or circulation (positional asphyxia) will lead to automatic refusal to be approved for delivery or to obtain their Certification.
This brings into question the competence of those within this Organisation tasked to assess physical restraint techniques. What training do they benefit from that allows them to competently assess physical restraint techniques? Further, what training do they receive that ensures they are competent to assess the contents of these holistically approached Risk Assessments they ask for?
Interestingly, NFPS previously evidenced that CQC inspectors, who have actively advocated for this Certifying Organisation, did not receive training that was suitable and sufficient to be competent to assess physical restraint techniques, and yet many Care providers have received poor responses from the CQC because they refuse to obtain this Certification; despite giving regard to their ‘Standards’ and having a fit-for-purpose welfare policy and restraint system already in play.
Remember, physical restraint is use of force, which must be reasonable in the circumstances. Therein lies the clue, circumstances and why the force being used is judged on the case-by-case circumstances in which it was applied. You simply cannot risk assess, holistically or otherwise, for every eventuality nor accurately assess the physical and psychological impact this use of force will have on the person being restrained; the staff executing the restraint techniques and anyone else directly or indirectly involved. Further, any restraint policy must not try remove an individuals’ right to do what is reasonable.
Again, the application of physical restraint techniques in operational settings is a DRA and management process, based on unique and multiple factors and not something that can competently be written in a static document.
NFPS stated long ago, that our system does give regard to these ‘Standards’ and is compliant with them, so far as they are legally defensible.
“Do You Have Risk Assessments For Your Restraint Techniques?”
This question, if asked, reflects a significant misunderstanding of risk assessment methodology and potentially overlooks professional responsibilities. It is wrong to assume that a singular, static document could ever adequately address the complex, dynamic, and situationally fluid nature of physical restraint techniques.
As stated above, a competent risk assessment requires a quantifiable, predictable set of conditions. Restrictive restraint techniques, by their very nature, occur in unpredictable, high-stress situations where the risks are dependent on a constantly shifting array of factors, including but not limited to:
- The physical and psychological state of the individual being restrained.
- The skill, physicality, psychological state and condition of the staff executing the restraint.
- The environment in which the restraint occurs (floor surface, obstacles, space constraints).
- The presence of weapons or hazardous objects.
- The behaviour presented, resistance, mindset and unpredictability of the individual being restrained.
- Pre-existing medical conditions that may influence outcomes and that an individual may have medical conditions unknown to staff.
To assume that a written risk assessment could comprehensively pre-determine, quantify, and mitigate all potential risks associated with restraint techniques overlooks the inherently dynamic nature of these situations. Effective risk management in this field relies on DRA, which remains the most viable approach.
Relying solely on static documents to predict the real-world risks of restraint presents significant challenges. For example, it would require a document that:
- Accounts for every possible size, weight, and medical condition of a restrained individual.
- Pre-determines the behaviour, intent, and resistance level of an aggressor in all possible scenarios.
- Considers and accounts for every conceivable environmental variable where a restraint might occur.
- Accurately quantifies the probability and severity of harm in all restraint scenarios.
‘Care’, ‘Management’ or ‘Restraint’ plans can of course inform staff of issues, conditions, best-practice techniques, and even the preferred technique option(s) as chosen by the person being restrained etc., however, these sorts of documents provide guidance to consider when assessing risks dynamically, as opposed to them being suitable and sufficient risk assessments themselves.
Remember, staff need to have the confidence and autonomy to do what is reasonable in the circumstances, always. Staff most certainly should not be made to believe that there are ‘absolute’ outcomes based on the contents of a risk assessment; there are no ‘absolutes’ when using physical restraint techniques during physical interventions.
I have tried to pre-empt some further statements and questions and provide cogent and robust responses here:
“Every Workplace Task Can Be Risk Assessed, So Why Not Restraint Techniques?”
Many workplace tasks involve controlled, repeatable actions where risks can be consistently measured and mitigated. Restrictive restraint techniques, however, occur in high-stress situations where variables change in real time.
The dynamic nature of restraint means risks must be assessed on the spot, not in advance via a static document.
“But Training Environments Are Controlled, So Surely You Can Risk Assess Restraint Training?”
The training environment itself can be, and absolutely should be, risk assessed for general hazards, but this is not the same as a competent risk assessment of the restraint techniques themselves.
The techniques still depend on the individuals involved, their physical conditions, and other uncontrollable variables that differ from real-world scenarios.
A particular technique that is “safe” in training may not be safe to execute in real life, and dependent on the unique set of circumstances inherent to that situation, making a general risk assessment unreliable. This evidences the requirement for both DRA and competently trained staff who are masters of a comprehensive restraint system; comprising of pressure-tested techniques sufficient to meet the challenges faced by the Organisation and ensure adequate duty of care.
“Surely If We Assess Size, Weight, And Vulnerabilities, We Can Quantify Risk?”
Even if you assess these factors, you still cannot predict how the individual will react in the moment.
Someone’s medical history or psychological state may be unknown, and they may react unpredictably under stress, increasing risk beyond what a static assessment could account for. Even if these factors are known, they may still react unpredictably.
“Medical Professionals Assess Medical Risks, So Why Can’t We Assess Restraint Risks?”
Medical risk assessments are condition-based (e.g., “what is the likelihood of infection after surgery?”). They rely on statistical predictability and controlled conditions.
Restraint risks are context-dependent (e.g., how much force is applied, environmental hazards, emotional state), making them impossible to standardise like medical risks.
A medical review can outline potential injuries, but it cannot predict probability and severity across different training and real-world scenarios
“Health And Safety Law Requires Risk Assessments, So Surely We Need One?”
Yes, Health and Safety law requires risk assessments, but they must be ‘suitable and sufficient’ in their construction.
For physical interventions, the law requires RM strategies, which include: restraint policy, staff training in physical restraint and physical interventions; adequate supervision at all levels, competent use of restraint equipment and restraint furniture; welfare monitoring, and de-escalation strategies.
A definitive RA for restraint techniques is not viable, because one cannot be written that would truly be ‘suitable and sufficient’.
“But Organisations Have Restraint Risk Assessments, So Surely It Can Be Done?”
Many organisations misuse the term RA when they actually mean policy guidance on restraint.
If you read these so-called RA’s, they typically list general considerations e.g., “staff should be trained,”; “monitor breathing,”; “avoid prone positions”; “potential ‘soft tissue’ injury”; “slips, trips and falls” etc., rather than a competently detailed, ‘suitable and sufficient’, quantitative RA.
“But Risk Assessments Help Reduce Injuries. Isn’t Something Better Than Nothing?”
‘Suitable and sufficient’ RA and RM of the use of physical restraints and physical interventions is designed to successfully facilitate the reduction of injuries. A generic RA for all individual restraint techniques cannot be achieved to any ‘suitable and sufficient’ standard.
Further, a poorly constructed RA may lead to false assurances and complacency, making staff believe that risks are fully controlled when they are not. The best way to reduce injuries is through continuous training, situational awareness, and real-time DRA.
Final Thought
If someone insists you can competently RA restraint techniques, ask them:
“Can you show me a written RA that accurately accounts for every possible individual, situation, and environment where the application of physical restraint techniques might occur?”
They won’t be able to, because it doesn’t exist.
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