Restrictive Practice Reduction Through Reviewing Staff Responses to Pain in PBS

May 17, 2026

Positive Behaviour Support requires providers to review whether pain, discomfort or health change may be contributing to distress and restrictive practice risk. The Positive Behaviour Support hub for rights, behaviour and restrictive practice reduction supports services to connect health awareness with dignity, safety and proactive support.

In specialist services, restrictive practice review and reduction should include incidents where pain may be mistaken for refusal, aggression, withdrawal, avoidance, restlessness, self-injury or resistance to personal care.

This reflects PBS principles around understanding, communication and person-led support, because behaviour may be the person’s clearest way of communicating discomfort when words, symbols or direct explanation are difficult.

Concept Explained Clearly

Pain-related restrictive practice occurs when staff respond to behaviour without checking whether the person may be uncomfortable, unwell or experiencing pain. This may include dental pain, constipation, infection, reflux, headache, menstrual pain, injury, skin irritation, medication side effects or fatigue linked to health conditions.

Staff responses become restrictive when pain is treated as behaviour to manage. The person may be prompted repeatedly, redirected, observed more closely, moved away from others or supported through routines that are causing pain.

PBS asks services to consider physical wellbeing as part of behaviour understanding. The aim is not to medicalise every behaviour, but to ensure pain is not missed before restrictive responses are used.

Why It Matters in Real Services

Many people receiving PBS-informed support may communicate pain indirectly. They may refuse food, push staff away, avoid sitting, hit their head, become withdrawn, pace, shout, resist touch or sleep differently.

If staff do not recognise these signs, support may become more controlling. A person refusing personal care because of pain may be treated as avoiding care. A person leaving activities because of discomfort may be redirected back repeatedly. Commissioners and CQC will expect providers to evidence that health and pain are considered when behaviour changes.

What Good Looks Like

Strong services know the person’s usual presentation and recognise changes. Plans describe individual pain indicators, communication methods, health escalation routes, medication guidance, clinical contacts and when staff must seek advice.

Providers should be able to evidence PBS plans, health action plans, body maps where relevant, pain profiles, incident reviews, clinical liaison, supervision records and outcome data. This creates a clear line of sight from behaviour change to health check, and from health action to reduced restrictive response.

Operational Example 1: Reviewing Refusal During Personal Care

Step 1 – Context: A person began refusing support with washing and became distressed when staff approached their shoulder area.

Step 2 – Support approach: Review showed this was a new pattern. Staff checked recent activity and identified possible pain after the person had fallen against a doorframe two days earlier.

Step 3 – Day-to-day delivery detail: Staff paused non-essential care tasks, used the person’s pain communication chart, arranged clinical review and adjusted support to avoid pressure on the affected side.

Step 4 – Restriction reduction: Staff stopped repeated prompting and avoided treating refusal as non-compliance while pain was assessed.

Step 5 – How effectiveness was evidenced: Distress reduced after treatment and adapted support. Personal care resumed gradually, and incident records showed fewer refusal-related escalations. The provider evidenced that health review reduced restrictive pressure.

Deepening the Approach

Pain review should examine change from baseline. Staff should ask what is different: movement, appetite, sleep, facial expression, tolerance of touch, posture, routine participation, continence, communication or mood.

Strong teams use evidence to identify patterns rather than assuming intent. Using ABC data to understand behaviour within PBS can help identify whether distress follows movement, eating, toileting, touch, specific times of day, fatigue, medication changes or physical routines.

Operational Example 2: Recognising Dental Pain Behind Mealtime Distress

Step 1 – Context: A person began leaving meals, pushing plates away and becoming distressed when staff encouraged them to eat.

Step 2 – Support approach: Review found the person was avoiding harder foods and touching one side of their face after meals.

Step 3 – Day-to-day delivery detail: Staff recorded food tolerance, offered softer alternatives, arranged dental review and reduced verbal prompts around eating.

Step 4 – Restriction reduction: Staff stopped treating mealtime refusal as behaviour to overcome and adjusted support while dental pain was investigated.

Step 5 – How effectiveness was evidenced: Dental treatment resolved the issue, food intake improved and mealtime prompts reduced. The provider evidenced that recognising pain prevented unnecessary restrictive mealtime responses.

Systems, Workforce and Consistency

Pain recognition must be consistent across the team. If one staff member notices subtle discomfort but this is not handed over clearly, the next shift may return to task-led prompting and increase distress.

Supervision should review how staff identify pain indicators, when they escalate concerns and how they record health-related behaviour change. Handovers should include sleep, appetite, posture, movement, medication changes, bowel patterns where relevant and any new signs of discomfort. Strong services demonstrate that health awareness is part of PBS practice, not separate from it.

Operational Example 3: Reviewing Increased Observation During Night Distress

Step 1 – Context: A person began waking at night, pacing and banging on doors. Staff increased observation because they were concerned about risk to others.

Step 2 – Support approach: Review showed the person was also holding their stomach and refusing breakfast. Health checks identified constipation and abdominal discomfort.

Step 3 – Day-to-day delivery detail: Staff followed clinical advice, increased fluid prompts in a low-pressure way, monitored bowel records and adapted night support to offer reassurance without crowding.

Step 4 – Restriction reduction: Increased night observation was stepped down once pain was treated and risk reduced.

Step 5 – How effectiveness was evidenced: Night waking reduced, door-banging stopped and staff recorded improved sleep. The provider evidenced that health-led action reduced the need for restrictive monitoring.

Governance and Evidence

Governance should show how pain and health factors are considered when behaviour changes. Providers should be able to evidence PBS reviews, incident analysis, health action plans, clinical referrals, medication reviews, supervision notes, body maps where appropriate and family or advocate input.

Strong governance creates a clear line of sight from behaviour change to health consideration, from health action to support adjustment, and from adjustment to outcome. Providers should be able to evidence that restrictive responses are not used before reasonable health checks have been considered.

Commissioner and CQC Expectations

Commissioners expect providers to understand behaviour holistically and escalate health concerns promptly. They need assurance that people are not restricted because pain communication has been missed.

CQC will expect care to be safe, responsive, person-centred and least restrictive. Inspectors may review whether staff recognise health changes, seek clinical advice, adapt support and learn from incidents. Strong services demonstrate that PBS includes physical wellbeing and that health-related distress is not managed through control.

Common Pitfalls

Assuming refusal is behavioural before checking discomfort or pain.
Continuing routines that may be causing pain.
Failing to record changes from the person’s usual presentation.
Increasing observation without investigating health causes.
Leaving pain indicators out of PBS plans and handovers.
Measuring success by task completion rather than comfort and wellbeing.

Conclusion

Restrictive practice reduction through reviewing staff responses to pain helps PBS services protect dignity, health and safety. Behaviour may be the clearest signal that something physically feels wrong.

Strong providers evidence how pain indicators are recognised, how health concerns are escalated and how support changes reduce distress. This gives commissioners and CQC confidence that PBS is grounded in whole-person understanding, not reactive behaviour management.