When we talk about reducing restrictive practice in dementia care, attention can quickly turn to what staff should do when a situation has already become difficult.

But reducing restriction often starts much earlier.

It starts with whether staff understand why a person may be distressed, how their own communication and approach can influence what happens next, and what can be changed before a situation escalates.

The Department of Health and Social Care’s current Care Workforce Pathway for Adult Social Care reinforces the importance of developing these broader capabilities.

The pathway sets out the knowledge, skills, values and behaviours needed across the adult social care workforce in England. For care and support workers, it also recognises that organisations need to determine setting-specific training based on the needs of the people they support.

For staff developing specialist practice in dementia care, the pathway points to the Dementia Training Standards Framework and suggests learning including Dementia Tier 2 training and positive behaviour support awareness training.

Elsewhere within the pathway, developing care workers are expected to understand areas including:

• mental capacity and consent
• restrictive practices and deprivation of liberty safeguards
• effective communication
• person-centred practice
• promoting choice and independence
• balancing individual rights with duty of care
• equality, inclusion and human rights.
• Taken together, this points towards something important.

Dementia training cannot only be about understanding dementia. It also needs to help staff understand and respond effectively to the person experiencing it.

Behaviour is rarely the whole story

Imagine someone living with dementia repeatedly trying to leave a care setting.

Staff might describe the behaviour as:

"Trying to abscond."

But that description tells us what the person is doing. It doesn't necessarily tell us why.

They may believe they need to collect their children.

They may be searching for somewhere familiar.

They may be frightened because they don't recognise where they are.

They may need the toilet but be unable to communicate it.

They may be in pain.

They may simply feel that somebody is preventing them from making a decision they believe they are perfectly entitled to make.

If we only respond to the observable behaviour, our options can quickly become focused on stopping the person.

If we understand what the behaviour may be communicating, more options become available.

That distinction matters when organisations are trying to reduce restrictive practice.

The interaction itself can change the level of risk

Consider what happens if a member of staff responds to the person at the door by repeatedly saying:

"You can't leave."

The staff member may have completely understandable safety concerns.

But from the person's perspective, they may now be confronted by somebody preventing them from doing something they believe they need to do.

The result might be increased anxiety, repeated attempts to leave, raised voices, pushing past staff or physical resistance.

What began as a concern about somebody leaving has now become a much more complex situation.

This doesn't mean staff should ignore risk or simply allow someone to place themselves in danger.

It means that how staff respond to risk can influence what happens next.

That is where specialist training becomes important.

From managing behaviour to understanding need

A preventative approach asks different questions.

Instead of only asking:

How do we stop this behaviour?

staff can begin to ask:

What might this behaviour be telling us?

That could mean considering:

• Is the person frightened, confused, uncomfortable or in pain?
• Is there an unmet need?
• Is something in the environment contributing to their distress?
• Has our communication increased or reduced their anxiety?
• Is the person trying to regain a sense of choice or control?
• What has worked for this individual previously?
• What is the least restrictive way we can safely respond?
• These are not simply theoretical questions.

They can directly influence whether an interaction remains manageable or develops into a situation where more restrictive responses are considered.

Communication is a preventative strategy

Effective communication is specifically identified within the Care Workforce Pathway, including the ability to understand and meet people's different communication needs, preferences and wishes.

This is particularly important in dementia care.

When someone's ability to process information, understand language, remember instructions or communicate their needs changes, simply repeating the same message more firmly may achieve very little.

Staff may need to change:

• the words they use
• how much information they provide at once
• their tone and pace
• their body language
• the choices they offer
• when they approach
• where the interaction takes place.
• Sometimes the most effective de-escalation strategy is not finding a better argument.

It is recognising that the current interaction isn't working and changing it.

Restrictive practice reduction requires more than awareness

Dementia awareness remains important.

Staff need to understand the condition and the ways it can affect cognition, communication and everyday functioning.

But awareness alone does not necessarily tell somebody what to do when a person is distressed, frightened, refusing care, trying to leave or responding physically to an interaction.

That requires the ability to apply knowledge in real situations.

A workforce seeking to reduce restrictive practice therefore needs practical capability in areas such as:

Understanding behaviour

Looking beyond what the person is doing and considering the physiological, psychological, environmental and interpersonal factors that may be influencing it.

Recognising distress early

Identifying changes in communication, behaviour or body language before distress develops into a crisis.

Adapting communication

Changing the interaction to meet the person's needs rather than expecting the person to adapt to ours.

Maintaining choice and dignity

Finding ways to support autonomy wherever possible while managing genuine risks.

Assessing risk dynamically

Recognising that risk changes throughout an interaction and adapting the response accordingly.

De-escalating safely

Using practical approaches that reduce anxiety, confrontation and escalation.

Learning afterwards

Looking beyond whether an incident was simply "managed successfully" and asking what contributed to it and what could reduce the likelihood of it happening again.

These capabilities help move restrictive-practice reduction from an organisational aspiration into something staff can influence during everyday interactions.

What should providers consider when reviewing dementia training?

The Care Workforce Pathway says organisations should define setting-specific training according to the needs of the people drawing on their care and support.

For providers supporting people living with dementia, that creates a useful question:

Does our training equip staff simply to understand dementia, or does it also equip them to prevent and respond to distress in ways that reduce the need for restrictive practice?

When reviewing training, providers may want to consider whether staff are being equipped to:

• understand behaviour as a form of communication
• identify possible causes of distress
• recognise environmental and interpersonal triggers
• respond to individual communication needs
• use positive behavioural approaches
• recognise escalation early
• balance safety, choice, dignity and individual rights
• use practical de-escalation strategies
• make proportionate decisions as risk changes
• understand and reduce restrictive practices
• reflect on incidents and contribute to future prevention.

This also reflects the direction of the updated Dementia Training Standards Framework, which is designed to help organisations develop dementia education, assess competence and strengthen workforce capability.

Specialist dementia training from Maybo

Maybo's approach to dementia care training starts with a simple principle:

Before we try to manage a behaviour, we need to understand what may be driving it.

Our Safer Approaches – Dementia training has been specifically developed for staff supporting older adults and people living with dementia.

The programme includes:

• Positive Approaches to Behaviour – Dementia
• Safer De-escalation – Dementia

Rather than beginning with physical intervention, the training focuses on prevention: understanding behaviour, identifying unmet needs and triggers, adapting communication, recognising distress and using positive approaches that can prevent situations escalating.

Staff then develop practical skills for assessing changing levels of risk and responding safely and respectfully when somebody becomes distressed.

The aim is not simply to teach staff how to respond more safely when an incident happens.

It is to help reduce the likelihood that restrictive intervention will be needed in the first place.

Maybo's dementia programme has also been reviewed against the Dementia Training Standards Framework, NICE Guideline NG97 and NICE Quality Standard QS184, with detailed mapping showing how its learning objectives support nationally recognised expectations for dementia care. For more information click the link 'maybo.com' in the sources box to the right.

This includes helping staff to:

• understand behaviour as communication
• recognise distress and escalation
• identify environmental, interpersonal and unmet-need triggers
• adapt verbal and non-verbal communication
• use positive behavioural support approaches
• make dynamic risk assessments
• prevent and de-escalate difficult situations
• balance individual rights, safety and safeguarding
• use preventative and least restrictive responses.

Reducing restriction starts before the incident

The Care Workforce Pathway provides another useful reminder that high-quality dementia care depends on more than knowledge of a diagnosis.

It requires staff who can understand the person, recognise what their behaviour may be communicating and adapt their response accordingly.

Because one of the most effective ways to reduce restrictive practice is not simply finding a safer way to intervene.

It is creating more opportunities not to intervene restrictively at all.

Maybo works with health and social care organisations to develop specialist dementia training that helps staff prevent distress, strengthen communication, reduce escalation and support safer, more dignified and less restrictive care.

Contact us to find out more about Maybo's training for older adults and people living with dementia.