CPT: 16TH GENERAL REPORT 49. Restraining an agitated or violent patient properly is no easy task for staff. Not only is training essential but refresher courses need to be organised at regular intervals. Such training should not only focus on instructing health-care staff how to apply means of restraint but, equally importantly, should ensure that they understand the impact the use of restraint may have on a patient and that they know how to care for a restrained patient. 50. The use of restraint in an appropriate manner requires considerable staff resources. For example, the CPT considers that when the limbs of a patient are held with straps or belts, a trained member of staff should be continuously present in order to maintain the therapeutic alliance and to provide assistance. Such assistance may include escorting the patient to a toilet facility or, in the exceptional case where the measure of restraint cannot be brought to an end in a matter of minutes, helping him/her to consume food. Clearly, video surveillance cannot replace such a continuous staff presence. In cases where a patient is secluded, the staff member may be outside the patient's room, provided that the patient can fully see the staff member and the latter can continuously observe and hear the patient. The adoption of a comprehensive restraint policy 51. Every psychiatric establishment should have a comprehensive, carefully developed, policy on restraint. The involvement and support of both staff and management in elaborating the policy is essential. Such a policy should make clear which means of restraint may be used, under what circumstances they may be applied, the practical means of their application, the supervision required and the action to be taken once the measure is terminated. The policy should also contain sections on other important issues such as: staff training; complaints policy; internal and external reporting mechanisms; and debriefing. In the CPT’s opinion, such a comprehensive policy is not only a major support for staff, but is also helpful in ensuring that patients and their guardians or proxies understand the rationale behind a measure of restraint that may be imposed. 17 Recording incidents of restraint 52. Experience has shown that detailed and accurate recording of instances of restraint can provide hospital management with an oversight of the extent of their occurrence and enable measures to be taken, where appropriate, to reduce their incidence. Preferably, a specific register should be established to record all instances of recourse to means of restraint. This would be in addition to the records contained within the patient’s personal medical file. The entries in the register should include the time at which the measure began and ended; the circumstances of the case; the reasons for resorting to the measure; the name of the doctor who ordered or approved it; and an account of any injuries sustained by patients or staff. Patients should be entitled to attach comments to the register, and should be informed of this; at their request, they should receive a copy of the full entry. 53. Regular reporting to an outside monitoring body, for instance a Health-Care Inspectorate, might be considered as well. The obvious advantage of such a reporting mechanism is that it would facilitate a national or regional overview of restraint practices, thus facilitating efforts to better understand and, consequently, manage their use. Final remarks 54. It should be acknowledged that resort to restraint measures appears to be substantially influenced by non-clinical factors such as staff perceptions of their role and patients’ awareness of their rights. Comparative studies have shown that the frequency of use of restraint, including seclusion, is a function not only of staffing levels, diagnoses of patients or material conditions on the ward, but also of the “culture and attitudes” of hospital staff. Reducing recourse to the use of restraint to a viable minimum requires a change of culture in many psychiatric establishments. The role of management is crucial in this regard. Unless the management encourages staff and offers them alternatives, an established practice of frequent recourse to means of restraint is likely to prevail.