Interventions for reducing the use of seclusion in psychiatric facilities: review of the literature

BACKGROUND

The authors of a recent systematic review concluded that the use of non-pharmacological containment methods, excluding restraint and seclusion, was not supported by evidence. Their focus on randomised, controlled trials, however, does not reflect the research that has been, or could be, conducted.

AIMS

To find empirically supported interventions that allow reduction in the use of seclusion in psychiatric facilities.

METHOD

We reviewed English-language, peer-reviewed literature on interventions that allow reduction in the use of seclusion.

RESULTS

Staff typically used multiple interventions, including state-level support, state policy and regulation changes, leadership, examinations of the practice contexts, staff integration, treatment plan improvement, increased staff to patient ratios, monitoring seclusion episodes, psychiatric emergency response teams, staff education, monitoring of patients, pharmacological interventions, treating patients as active participants in seclusion reduction interventions, changing the therapeutic environment, changing the facility environment, adopting a facility focus, and improving staff safety and welfare.

CONCLUSIONS

Reducing seclusion rates is challenging and generally requires staff to implement several interventions.

Use of physical restraint in nursing homes: clinical-ethical considerations

This article gives a brief overview of the state of the art concerning physical restraint use among older persons in nursing homes. Within this context we identify some essential values and norms that must be observed in an ethical evaluation of physical restraint. These values and norms provide the ethical foundation for a number of concrete recommendations that could give clinical and ethical support to caregivers when they make decisions about physical restraint. Respect for the autonomy and overall wellbeing of older persons, a proportional assessment of the advantages and disadvantages, a priority focus on the alternatives to physical restraint, individualised care, interdisciplinary decision making, and an institutional policy are the central points that make it possible to deal responsibly with the use of physical restraint for older persons in nursing homes.

Nurses' decision-making in cases of physical restraint: a synthesis of qualitative evidence

AIM

  This article is a report of a review that aimed to synthesize the available qualitative evidence on nurses' decision-making in cases of physical restraint.

BACKGROUND

  The use of physical restraint in acute and residential healthcare facilities is a widespread practice in many countries. Decisions about the use of physical restraints are complex and ethically laden. The lack of evidence supporting the use of physical restraints, the negative consequences of restraint for patients, and the low availability of alternatives obviously complicate the decision-making.

DATA SOURCES

  Research papers published between January 1990 and January 2010 were identified in Cinahl, Embase, Medline, PsycInfo and Web of Science.

REVIEW METHODS

  A systematic review was carried out to obtain a meta-synthesis of qualitative evidence. The process of meta-synthesis was supported by the Joanna Briggs Institute's guidelines.

FINDINGS

  The decision-making of nurses dealing with the use of physical restraints is a complex trajectory primarily focused on safety. However, thoughtful decision-making requires nurses to carefully balance different options and associated ethical values. The decision-making process of nurses is influenced by both nurse- and context-related factors.

CONCLUSIONS

  This review provides a deeper understanding of nurses' decision-making process on the use of physical restraints. Context- and nurse-related factors can hinder nurses from making an ethical decision on the appropriate use of physical restraints. There is an urgent need to stimulate and educate nurses to arrive at an appropriate decision about the use of physical restraints.

British Association of Critical Care Nurses position statement on the use of restraint in adult critical care units

Critical care nurses in the United Kingdom have become increasingly concerned about the use, potential abuse and risks associated with physical restraint of patients. Restraint in critical care is not only confined to physical restraint but can also encompass chemical and psychological methods. There are concerns regarding the legal and ethical issues relating to the (ab)use of physical restraint techniques in critical care. The aim of this article was to present the British Association of Critical Care Nurses (BACCN) position statement on the use of restraint in adult critical care units and to provide supporting evidence to assist clinical staff in managing this process.

Nurses' feelings and thoughts about using physical restraints on hospitalized older patients

AIM

To explore nurses' feelings and thoughts about physically restraining older hospitalized patients.

BACKGROUND

The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan.

DESIGN AND METHODS

A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data.

RESULTS

Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings.

CONCLUSIONS

Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.

The use of physical restraint in critical care

Critically ill patients are at high risk for the development of delirium and agitation, resulting in non-compliance with life-saving treatment. The use of physical restraint appears to be a useful and simple solution to prevent this treatment interference. In reality, restraint is a complex topic, encompassing physical, psychological, legal and ethical issues. This article briefly discusses the incidence of delirium and agitation in critically ill patients and examines in detail the method of physical restraint to manage treatment interference. The historical background of physical restraint is discussed and the prevalence of its use in critical care units across the world examined. Studies into the use of physical restraint are analysed, and in particular the physical effects on patients discussed. The use of physical restraint raises many legal, ethical and moral questions for all health care professionals; therefore, this study aims to address these questions. This article concludes by emphasizing areas of future practice development in intensive care units throughout the UK.

Can we justify eliminating coercive measures in psychiatry?

The practice of coercive measures in psychiatry is controversial. Although some have suggested that it may be acceptable if patients are a danger to others or to themselves, others committed themselves to eliminate it. Ethical, legal and clinical considerations become more complex when the mental incapacity is temporary and when the coercive measures serve to restore autonomy. We discuss these issues, addressing the conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive measures. We argue that an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. The total lack of controlled trials about the beneficial effects of coercive measures in different populations however, argues against the use of coercive measures.

Restraint and the Question of Validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

Induction of anesthesia in a combative child; management and issues

A developmentally delayed, 13-year old autistic boy required management of multifocal cerebral and pulmonary tumors, involving several anesthetics over a 4-month period. At each anesthetic he refused premedication, displayed increasing anxiety and became more combative. With parental guidance and involvement, a variety of anesthetists tried a range of techniques to achieve induction, each ultimately resorting to the use of physical restraint. Principles essential to the care of such a child include early recognition, parental support, multi-disciplinary planning of procedures requiring general anesthesia, continuity of anesthesia care, and clear guidelines about the perioperative management of uncooperative children, including the ethical use of restraint.

Solving Ethically Difficult Care Situations in Nursing Homes

Patients in nursing homes sometimes give accounts of episodes in which they feel their autonomy and/or self-respect are violated as a result of the care they receive from nursing staff. In these ethically difficult care situations nurses use strategies such as negotiation, explanation and, in some cases, restraint. This study investigates how nurses apply these strategies to resolve ethical dilemmas in such a way that patients experience respect rather than violation. Critical issues that will be discussed include the definition of ethically difficult care situations in nursing homes and the identification of strategies for resolving such situations. Examples of the use of three strategies are presented. The use of negotiation, restraint and explanation are discussed in order to ensure respect for patients’ autonomy and thus to optimize health care outcomes.

Assessing Animal Welfare Impacts in the Management of European Rabbits (Oryctolagus cuniculus), European Moles (Talpa europaea) and Carrion Crows (Corvus corone)

Human-wildlife conflict is a global issue. Attempts to manage this conflict impact upon wild animal welfare, an issue receiving little attention until relatively recently. Where human activities harm animal welfare these effects should be minimised where possible. However, little is known about the welfare impacts of different wildlife management interventions, and opinions on impacts vary widely. Welfare impacts therefore need to be assessed objectively. Our objectives were to: 1) establish whether an existing welfare assessment model could differentiate and rank the impacts of different wildlife management interventions (for decision-making purposes); 2) identify and evaluate any additional benefits of making formal welfare assessments; and 3) illustrate issues raised by application of the model. We applied the welfare assessment model to interventions commonly used with rabbits (Oryctolagus cuniculus), moles (Talpa europaea) and crows (Corvus corone) in the UK. The model ranked interventions for rabbits (least impact first: fencing, head shot, chest shot) and crows (shooting, scaring, live trapping with cervical dislocation). For moles, managing molehills and tunnels scored least impact. Both spring trapping, and live trapping followed by translocation, scored greater impacts, but these could not be compared directly as they scored on different axes of the model. Some rankings appeared counter-intuitive, highlighting the need for objective formal welfare assessments. As well as ranking the humaneness of interventions, the model highlighted future research needs and how Standard Operating Procedures might be improved. The model is a milestone in assessing wildlife management welfare impacts, but our research revealed some limitations of the model and we discuss likely challenges in resolving these. In future, the model might be developed to improve its utility, e.g. by refining the time-scales. It might also be used to reach consensus among stakeholders about relative welfare impacts or to identify ways of improving wildlife management practice in the field.

The use of physical restraints for patients suffering from dementia

This study reviews the ethical dilemmas of nursing staff about using restraints on patients suffering from dementia in two types of health care settings in Israel: internal medicine wards of three general hospitals; and psychogeriatric wards of three nursing homes. The nurses' level of knowledge about the Patient's Rights Law, the Israeli Code of Ethics, and the guidelines on restraints was analysed. The purposes of restraints were defined as beneficial to: (1) the patient; (2) other patients; or (3) the institution. The concept was evaluated in a realistic situation (expressing views of daily practice) and in an idealistic situation (expressing personal and professional beliefs and values). It was shown that nurses in internal medicine wards of general hospitals agreed more with the use of restraints than those in psychogeriatric wards in nursing homes. Differences were more pronounced when restraints were beneficial to the institution. In addition, nurses working in psychogeriatric wards of nursing homes had more knowledge about the guidelines on restraints and were less inclined than their counterparts to agree with the use of restraints for the benefit of other patients or the institution.

The use of restraint in the treatment of paediatric dental patients: old and new insights

OBJECTIVE

This article reviews aspects of the restraint strategies in paediatric dentistry that have been reviewed in recent years and point out those strategies that remain controversial as well as questionable.

METHODS

Studies that evaluated demographic and cultural factors that influence dentists' use of restraint, discussion of the rationale behind the use of restraint, the role of parents, informed consent, use of restraints at the undergraduate and at the postgraduate level, and some ethical questions were selected.

CONCLUSIONS

Practice location, caries prevalence, and the educational backgrounds of the dentist played a role in the selection of behavioural strategies. Use of these techniques varied depending on the age of the dentist and the dental school from which the dentist had graduated. Parents are one leg of the child/dentist/parent triangle and therefore have a role to play in the determination of treatment strategies. Dentists must select techniques that help to instill a positive dental attitude in the child by performing treatment effectively and efficiently. Dentists must inform parents of all aspects of the applied strategy and must have their approval.

EVERYDAY ETHICS in Assisted Living Facilities: A Framework for Assessing Resident-Focused Issues

This article describes and illustrates a framework that may be used when assessing the moral basis of everyday issues that can affect residents of assisted living facilities. The "taxonomy of everyday ethical issues" was an outcome of ethnographic research focused on care of nursing home residents with dementia. However, in this article it is shown to be equally relevant for conceptualizing issues affecting cognitively intact as well as cognitively impaired residents across these two settings. The taxonomy is grounded in some of the more common cultural characteristics of congregate living arrangements for elderly individuals who have needs for varying levels of compensatory and therapeutic oversight by a staff of service providers.

Physical Restraint during Procedures: Issues and Implications for Practice

Physical restraint or holding down a child or young person with cancer is generally accepted to ensure success in carrying out the various procedures involved throughout the disease trajectory. Over the past several years, health care staff have become more aware of the issues surrounding physical restraint. However, the research around the effects of being involved in physical restraint is extremely limited. Nurses continue to have little education in the pertinent issues, restraint techniques, and alternative strategies. This article aims to highlight areas that nurses caring for children and young people with cancer need to consider. Strategies for improving practice are also discussed with the thought that nurses will be stimulated to re-evaluate the use of physical restraint in this group of children and young people.

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review

BACKGROUND

Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay.

METHODS

Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out.

RESULTS

Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22).

CONCLUSIONS

The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.

A synthesis of what we know about the use of physical restraints and seclusion with patients in psychiatric and acute care settings: 2003 update

PURPOSE

This article is an update of the January 19, 2000, Volume 7, Number 2 article of the synthesis of research findings on the use of restraint and seclusion with patients in psychiatric and acute care settings.

CONCLUSIONS

The little that is known about restraint/seclusion use with these populations is inconsistent. Attitudes and perceptions of patients, family, and staff differ. However, all patients had very negative feelings about both, whether they were restrained/secluded or observed by others who were not restrained. The reasons for restraint/seclusion use vary with no accurate use rate for either. What precipitates the use of restraint/seclusion also varies, but professionals claim they are necessary to prevent/treat violent or unruly behavior. Some believe seclusion/restraint is effective, but there is no empirical evidence to support this belief. Many less restrictive alternatives have been tested with varying outcomes. Several educational programs to help staff learn about different ways to handle violent/confused patients have been successful.

IMPLICATIONS

Until more is known about restraint/seclusion use from prospective controlled research, the goal to use least restrictive methods must be pursued. More staff educational programs must be offered and the evaluation of alternatives to restraint/seclusion pursued. When seclusion/restraint is necessary, it should be used less arbitrarily, less frequently, and with less trauma. As the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Health Care Financing Administration (HCFA) have prescribed, "Seclusion and restraint must be a last resort, emergency response to a crisis situation that presents imminent risk of harm to the patient, staff, or others" (p. 25) [99A].

Exercising restraint: Clinical, legal and ethical considerations for the patient with Alzheimer’s disease

The number of older people using emergency care is increasing steadily and older people account for over half of all emergency admissions. In the emergency setting, nurses caring for older people with Alzheimer's disease can be faced with many complex ethical and legal challenges. Moreover, challenges such as the use of physical restraint can precipitate conflict when the nurse is placed in the precarious position of doing good, respecting autonomy and avoiding paternalism. Although, there is no complete set of "rules" that can provide nurses with an answer to each dilemma, it is of significant value for nurses to have sound knowledge of ethical and legal positions in order to analyse the many complex situations that they may encounter.

Restraint and self-injury in people with intellectual disabilities: a review

Most of the recent debate concerning the ethics of physical interventions has focused on the management of aggressive and destructive behaviours, neglecting the management of self-injurious behaviour. This is an important omission, given the extremely serious consequences that can arise from this form of challenging behaviour. The present article reviews types of restraint used to manage self-injury, prevalence of use, and main and side effects of restraint use. It describes some good practice standards and highlights the need for further research and debate in this complex area.

Ethical dilemmas in forensic psychiatry: two illustrative cases

One approach to the analysis of ethical dilemmas in medical practice uses the "four principles plus scope" approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles.

A good death

The Institute of Medicine defines a good death a “one that is free from avoidable death and suffering for patients, families and caregivers in general accordance with the patients’ and families’ wishes.”. The current system creates barriers to reducing the stress and suffering that accompany a patient’s end of life. Data and eHealth technology, if it were more accessible, could help patients, families, and caregivers to cope with end of life issues.

Use of restraints on dementia patients: an ethical dilemma of a nursing staff in Israel

This quality improvement project investigates the ethical dilemmas faced by nursing staff (ie, registered nurses, practical nurses, and nurse aids) using restraints for dementia patients in "realistic" and "idealistic" situations.

RATIONALE

There is a need to offer adequate care for a growing number of patients suffering from dementia and to ensure their safety. Restraints are a common practice for this purpose; however, they may inflict harm and contradict patient rights of freedom, autonomy, and respect. The issue becomes more complex in view of the multiple studies showing that the various justifications for using restraints are often based on caregiver interests and institutional considerations rather than on the patient's benefit.

DESIGN

The project was conducted on a sample of 200 Israeli nursing staff members, half from internal medicine wards of 3 hospitals and the other half from 3 psychogeriatric nursing homes, all treating dementia patients. The project used a questionnaire composed of demographic data and an ethical preference questionnaire built on 18 situations concerning restraints. Situations were categorized into 3 purposes: (a) patient's benefit, (b) other patients' benefit, and (c) institutional benefit. These situations referred to realistic (ie, expressing views of daily practice) and idealistic (ie, expressing personal and professional beliefs and values) situations.

RESULTS

The project exposes a discrepancy between the manner in which the nursing staff perceive use of restraints in an idealistic situation and in a realistic situation and the greater tendency to use restraints in the realistic situation than in the idealistic situation. The main contribution of the project is in revealing the conflict between the personal beliefs of the nursing staff and the nurses' perceptions of their institutional obligations.

CONCLUSIONS

The project uncovered a discrepancy among the beliefs, the personal and professional values of the nursing staff, and their perception regarding the actual use of restraints in the daily work routine.