Physical restraint in mental health nursing: A concept analysis

Brazilian Psychiatric Association Consensus on the physical structure and ideal team for psychiatric emergencies services

INTRODUCTION

An integral part of Brazil's public health system, the psychiatric emergency service (PES) has been instrumental in improving qualified support for crisis situations of mental disorders, equitable, universally accessible, and humanized. The purpose of this article is to present a systematic review and consensus about the physical area and facilities, and ideal team qualified for psychiatric emergencies services on both Brazilian settings.

METHODS

The authors conducted a literature search using electronic databases such as MEDLINE (PubMed), Scielo, the Cochrane Database, and documents from the WHO, the Brazilian Ministry of Health, and others deemed relevant by experts. A total of 6839 manuscripts were found, but only 46 were selected. The analysis of article content summarizes consensus statements using the Delphi method and a series of interactive versions to provide a final report.

RESULTS

Changes to PES are evaluated considering various experiences and models. The authors highlighted that The Emergency Care Network (ECN) must be coordinated with qualified management, effective implementation of integration of all health equipment's and units. PES must have adequate infrastructure; qualified staff, including a psychiatrist; sufficient consultation and observational spaces; tools and resources for differential diagnosis; training for all staff members; and communication with the health care network to facilitate referrals following patient discharge are all necessary.

CONCLUSION

These standardized models need to be available to public health managers so that they can guide the installation of new services and adjust the existing ones, always looking for improvement. The authors propose requirements for PES as a model to be passed over.

Assessment of Nurses' Knowledge, Attitude and Practice Regarding Physical Restraint: A Scoping Review

The use of physical restraints (PR) in healthcare settings, especially in psychiatric units, is a controversial topic. The attitude, knowledge, and practices of nurses towards PR can influence its application, which raises concerns about the balance between patient safety and individual rights. With mental disorders being a leading cause of disability globally, understanding the complexities surrounding PR use becomes paramount. A comprehensive literature review was conducted using multiple databases, including PubMed, Medline, CINAHL, PsycINFO, ProQuest, The Cochrane Library, the Saudi Digital Library, and Google Scholar. The search spanned literature published up to December 2022, focusing on studies that explored the relationship between nurses' knowledge, attitudes, and practices regarding PR in psychiatric settings. Inclusion and exclusion criteria were applied to filter out relevant studies. From 220 records initially retrieved, 12 articles were identified for the final review. The reviewed studies highlighted a moderate knowledge and attitude among nurses concerning PR. Many nurses were found to be uncertain about the reasons for PR application and its alternatives. Educational interventions were emphasized in several studies as beneficial in improving nurses' knowledge, attitudes, and practices. However, inconsistencies were observed regarding the impact of these interventions on nurses' attitudes. Experience, higher education, and continuous training sessions were found to be correlated with better knowledge and more favourable attitudes towards PR. This review emphasizes the critical need for consistent training and education for nurses regarding PR, given the profound implications for patient care and safety. While educational interventions show promise in enhancing knowledge and practice, their impact on attitudes remains contested. Future research should consider the gaps identified in this review, including the exploration of alternatives to PR, larger sample sizes and longitudinal studies to understand the long-term effects of interventions.

Is physical restraint unethical and illegal?: a qualitative analysis of Korean written judgments

BACKGROUND

Physical restraint (PR) is used to ensure the safety of care recipients. However, this causes an ethical dilemma between the autonomy and dignity of the recipients and the provision of effective treatment by health workers. This study aimed to analyze legal and ethical situations related to the use of PR using written judgments.

METHODS

This study uses a qualitative retrospective design. Qualitative content analysis was performed on South Korean written judgments. A total of 38 cases from 2015 to 2021 were categorized. The types of court decisions and ethical dilemma situations were examined according to the four principles of bioethics, and the courts' judgments were compared.

RESULTS

Written judgments related to PR were classified into three types according to the appropriateness of PR use, the presence or absence of duty of care, and legal negligence. Ethical dilemmas were categorized into three situations depending on whether the four principles of bioethics were followed. The courts' decisions regarding the ethical dilemmas differed depending on the situational factors before and after the use of PR and the conflicting conditions of the ethical principles.

CONCLUSIONS

Health workers should consider legal and ethical requirements when determining whether to use PR to provide the care recipient with the necessary treatment.

Perspectives on physical restraint in psychiatric hospital: A qualitative study of mentally ill patients

The use of physical restraint had caused a series of unexpected impacts on patients, particularly psychological trauma. This qualitative study aimed to identify perspectives on physical restraint among patients with mental health conditions and to seek effective interventions targeting the psychological trauma which is caused by physical restraint. A semi-structured interview was conducted in a public psychiatric hospital in China to explore perspectives on physical restraint among 26 patients who had undergone or witnessed physical restraint. The interview was conducted by experienced and qualified interviewers with mental health service backgrounds. The interviews were recorded and transcribed into words, and then preliminary themes were extracted and coded, finally thematic analysis was used to identify focused themes. Five themes were extracted: these were as follows: (1) The negative effects of physical restraint on patients; (2) The impairment of the relationship between nurse and patient due to physical restraint; (3) The decrease in patients' treatment adherence caused by physical restraint; (4) The positive outcomes of physical restraint; (5) The expectations of patients for improving the quality of nursing care. Conclusively, the use of physical restraint had critical impacts on patients, including psychological trauma, destruction of the nurse-patient relationship, and decreased adherence of treatment. These negative effects could impede clinical work.

Forensic mental health nurses' experiences of rebuilding the therapeutic relationship after an episode of physical restraint in forensic services in Ireland: A qualitative study

Few studies have explored how forensic mental health nurses can rebuild the therapeutic relationship following an episode of physical restraint in the acute forensic setting. In this study, we aimed to redress this gap in the literature by exploring with forensic mental health nurses the factors that enable or hinder the rebuilding of the therapeutic relationship following an episode of physical restraint. A qualitative study design was used to capture participants' experiences, views and perceptions of the therapeutic relationship following an episode of physical restraint in the acute forensic setting. Data were collected through individual interviews with forensic mental health nurses (n = 10) working in an acute forensic setting. Interviews were audio recorded, and transcribed verbatim and accounts were analysed using thematic analysis. Four themes were identified: 'Building a Recovery Focused Therapeutic Relationship'; 'Authoritarian Role'; 'Inevitable Imbalance'; 'Rebuilding the Therapeutic Relationship'; plus two sub-themes 'Facilitators to rebuilding' and 'Barriers to rebuilding'. Findings suggest that an inevitable imbalance exists in building a recovery-focused therapeutic relationship and at times, is hindered by the authoritarian role of the forensic mental health nurse. Recommendations for changes in clinical practice and in upcoming policies should incorporate a dedicated debrief room and protected time for staff to debrief effectively following restraint. Routine post-restraint-focused clinical supervision would also be beneficial to mental health nursing staff.

Psychiatric Nurses' Knowledge, Attitudes, and Practice Regarding Physical Restraint in China: A Multicentre Cross-Sectional Study

Background

Physical restraint is widely used in mental health services to address safety concerns. However, studies have shown that improper physical restraint can result in adverse effects. Nurses are the main practitioners of physical restraint and play a crucial role in physical restraint decisions and nursing. In China, there is a lack of large-scale investigations into the current status of psychiatric physical restraint use.

Aim

This study aims to explore the situation and influencing factors of the psychiatric nurses' knowledge, attitudes and practices regarding physical restraint in China.

Methods

A cross-sectional multicenter descriptive study was conducted from December 2022 to February 2023, consecutively. A convenience sampling method was used to recruit 345 staff from three psychiatric hospitals in Shanghai. A psychiatric nurses' physical restraint use status questionnaire was administered to examine their knowledge, attitude, and practice regarding physical restraint. The data were analyzed using the Mann-Whitney U-test and the Kruskal-Wallis test. Multivariate linear stepwise regression analysis was used for multi-factor analysis.

Results

Overall, nurses had a good level of knowledge with positive attitudes and adequate practices. However, they had some misunderstandings and undesirable practices. Multiple linear regression analysis revealed that educational background, position and training experience were the main factors influencing physical restraint knowledge, attitudes and practice among psychiatric nurses (p<0.05).

Conclusion

This study highlights some important misconceptions and improper practices of psychiatric nurses about using physical restraint. It is necessary to strengthen education and training on physical restraint for nursing staff to reduce unnecessary physical restraint use.

Algorithmic Prediction of Restraint and Seclusion in an Inpatient Child and Adolescent Psychiatric Population

BACKGROUND

Restraint and seclusion in an inpatient child and adolescent psychiatric population adversely affects the overall value and safety of care. Due to adverse events, negative outcomes, and associated costs, inpatient psychiatric hospitals must strive to reduce and ultimately eliminate restraint and seclusion with innovative, data-driven approaches.

AIM

To identify patterns of client characteristics that are associated with restraint and seclusion in an inpatient child and adolescent psychiatric population.

METHOD

A machine learning application of fast-and-frugal tree modeling was used to analyze the sample.

RESULTS

The need for restraint and seclusion were correctly predicted for 73% of clients at risk (sensitivity), and 76% of clients were correctly predicted as negative or low risk (specificity), for needing restraint and seclusion based on the following characteristics: having a disruptive mood dysregulation disorder and/or attention-deficit hyperactivity disorder diagnosis, being 12 years old or younger, and not having a depressive and/or bipolar disorder diagnosis.

CONCLUSIONS

The client characteristics identified in the predictive algorithm should be reviewed on admission to recognize clients at risk for restraint and seclusion. For those at risk, interventions should be developed into an individualized client treatment plan to facilitate a proactive approach in preventing behavioral emergencies requiring restraint and seclusion.

Risk factors of self-extubation in intensive care. Retrospective cohort study

Introduction: Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective: To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods: The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results: A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.01) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions: The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.

Experience of mental health nurses regarding mechanical restraint in patients with psychomotor agitation: A qualitative study

AIM

To explore mental health nurses' experiences whilst managing a patient with psychomotor agitation, and the factors that influence the decision to use mechanical restraints.

BACKGROUND

Psychomotor agitation is considered a potentially violent psychiatric emergency. The management of disruptive behaviours includes mechanical restraints as the last resort although its use has consequences for patients, professionals and the therapeutic relationship.

DESIGN

A qualitative study design with a hermeneutical approach was developed.

METHODS

A total of 31 nurses were purposively sampled from six short- and medium-stay mental health inpatient units. Data were obtained from semi-structured interviews. A thematic content analysis following the seven steps of Colaizzi's method was performed. Three researchers independently conducted an inductive analysis within a perspective of a hermeneutic paradigm. The COREQ checklist was followed in carrying out this research.

RESULTS

Four themes emerged from the analysis: 1) Nurses' perceptions of restraint methods, 2) Factors influencing decision-making, 3) Consequences for professionals of the use of mechanical restraint and 4) Alternatives to mechanical restraint.

CONCLUSIONS

Aspects such as the importance of teamwork, the issue of cognitive dissonance, ethical conflict and barriers to effecting the withdrawal of these measures affect the mental health nurse's decision-making process. The understanding of these aspects is crucial to further reducing its incidence and negative consequences and achieving the elimination of mechanical restraints.

RELEVANCE FOR CLINICAL PRACTICE

Knowing how nurses feel during the patient's episode of psychomotor agitation and which factors influence the decision on whether to apply coercive methods can guide us on the quality of care offered.

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 December 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged ≥40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed.

Physical Restraint in Psychiatric Care: Soon to Fall Out of Use?

International directives all recommend that using restraints on psychiatric patients should be avoided, yet scientific literature shows that such practices are still largely in use. This article aims to lay out strategies that could be put in place in order to gradually discard the use of restraints, particularly through a "restraint-free" approach, nursing, logistic-environmental pathways, and locally centered health care provision. All such tools have proven valuable for the purpose of safeguarding the health of psychiatric patients. Hence, the failure to put in place such measures may lead to litigation and lawsuits against physicians and particularly health care facilities. Undoubtedly, the ability to effectively implement such methods largely depends on the financial resources available, which in countries such as Italy are poorer than in others. Still, the risk of being sued and held professionally liable may constitute a factor in raising awareness among operators, facilities, and public health care management, leading to the implementation of policy changes aimed at minimizing the use of restraints.

Patient Risk Factors for Violent Restraint Use in a Children's Hospital Medical Unit

BACKGROUND AND OBJECTIVES

To inform efforts to reduce violent restraint use, we examined risk factors for restraint use among hospitalized children with known behavior concerns.

METHODS

We conducted a retrospective cross-sectional study of restraint events in all hospitalizations from 2017 to 2019 on a 10-bed medical-surgical unit with dedicated mental health clinician support. We examined characteristics of restraint events, used adjusted logistic regression models to identify independent risk factors for restraint use, and used an adjusted Poisson regression model to determine the adjusted rate of restraint events per hospital day.

RESULTS

The sample included 1507 hospitalizations representing 1235 patients. Among included hospitalizations, 48% were for a psychiatric indication awaiting transfer to an inpatient psychiatric unit, and 52% were for a primary medical or surgical problem. Sixteen percent had a restraint event. Patient demographic characteristics were not associated with risk of a restraint event. Having a psychiatric indication for hospitalization was an independent risk factor for restraint use (odds ratio: 2.85; 95% confidence interval: 2.06-3.94). Rate of restraint use per day decreased as length of stay increased; hospitalizations lasting 9 days or longer had a 58% lower rate of restraint use per day than 1- to 2-day hospitalizations (P < .001).

CONCLUSIONS

Interventions to reduce restraint use may benefit from incorporating information about a patient's psychiatric risk factors, including type and number of diagnoses and reason for hospitalization. Future efforts could investigate whether providing enhanced behavior supports during the first several days of a patient's hospitalization reduces violent restraint use.

The Knowledge, Practice and Attitudes of Nurses Regarding Physical Restraint: Survey Results from Psychiatric Inpatient Settings

There is a considerable amount of literature describing how nurses’ knowledge contributes to their attitudes and practices related to patient physical restraint. However, whether or not there have been any improvements in nurses’ knowledge levels, attitudes or practices regarding physical restraint during the past few years is unknown. A survey was conducted on nurses (n = 133) in one psychiatric hospital in Hong Kong (n = 98, response rate = 74%). The data were analyzed using independent t-tests, ANOVA, a Mann–Whitney U test, a Kruskal–Wallis test and Spearman’s rho. In general, nurses had good restraint-related knowledge with satisfactory attitudes and practices, although their knowledge levels, attitudes, and practices regarding restraint varied. Having a higher age, seniority, and education level contributed to a higher restraint-related knowledge level. Male nurses demonstrated more desirable practices (i.e., care of restrained patients), while nurses with a higher education level were more likely to avoid restraint. Nurses’ restraint-related knowledge positively correlated with restraint practices. Although nurses’ knowledge levels, attitudes, and practices regarding restraint were found to be satisfactory, more training efforts should focus on young nurses working in psychiatric settings with less work experience and lower education levels. As some nurses seem to favor the use of restraint with limited reflection, more studies are needed to verify nurses’ emotions and how their emotions influence the use of restrictive practices.

Attitude and practice toward physical restraint among psychiatric nurses in Guangdong, China: a cross-sectional survey†

Objective

To explore the correlation between nurses’ attitude and practice toward physical restraint (PR) in psychiatric settings and identify the factors that influence the use of PR.

Methods

A cross-sectional survey was conducted. A self-designed questionnaire containing a PR scale was used to assess the attitude and practice of registered psychiatric nurses in Guangdong, China, from November 1, 2018 to December 31, 2018. Descriptive statistics, the Mann–Whitney U test, the Kruskal–Wallis test, and ordinal regression analysis were used to analyze the data.

Results

The response rate was 74.6%. The nurses’ responses showed neutral attitude and a moderate level of practice regarding the use of PR. Factors such as age, gender, marital status, professional position, nightshift, and the frequency of training programs on PR showed a significant association with nurses’ attitude and practice concerning PR (P < 0.05). In addition to these factors, this study found that the practice of PR was associated with nurses’ attitude toward it (P < 0.05). Our results showed that nurses with a largely negative attitude toward PR were more likely to use it (OR = 1.91, P < 0.001).

Conclusions

Clinically, psychiatric nurses with negative attitude are more likely to practice PR. Training and education programs are highly recommended for nursing managers to change the nursing staff’s attitude, since their attitude may have an impact on the PR what they practice.

Mindfulness, Compassion, and Self-Compassion as Moderator of Environmental Support on Competency in Mental Health Nursing

This research explored the established relationship between environmental support and competency for Mental Health Nurses, intending to investigate whether the tendency to display higher levels of mindfulness, compassion, and self-compassion might buffer the effect of a poor environment on competency. One questionnaire was comprised of five pre-developed questionnaires, which included all items examining environmental support, competency, mindfulness, compassion, and self-compassion. Mental Health Nurses (n = 103) were recruited from online forums and social media group pages in the UK. The result showed environmental support related positively to competency. Furthermore, the positive relationship of competency with environmental support was moderated when controlling for compassion but did not with mindfulness and self-compassion, although subscales showed some further interactions. When poor environmental support influences the competency of mental health professionals, compassion and mindfulness-based interactions may have the potential to uphold competency.

Effectiveness of CRSCE-Based De-escalation Training on Reducing Physical Restraint in Psychiatric Hospitals: A Cluster Randomized Controlled Trial

Background: The use of physical restraint (PR) causes clinical and ethical issues; great efforts are being made to reduce the use of PR in psychiatric hospitals globally. Aim: This study aimed to examine the effectiveness of CRSCE-based de-escalation training on reducing PR in psychiatric hospitals. Method: The proposed study adopted cluster randomized controlled trial design. Twelve wards of a psychiatric hospital were randomly allocated to experimental group (n = 6) and control group (n = 6). Wards of control group were assigned to routine training regarding PR; wards of experimental group underwent the same routine training while additionally received CRSCE-based de-escalation training. Before and after CRSCE-based de-escalation training, the frequency of and the duration of PR, and the numbers and level of unexpected events caused by PR, were recorded. Results: After CRSCE-based de-escalation training, the frequency (inpatients and patients admitted within 24 h) of and the duration of PR of experimental group, showed a descending trend and were significantly lower than those of control group (P < 0.01); compared to control group, the numbers of unexpected events (level II and level III) and injury caused by PR of experimental group had been markedly reduced (P < 0.05). Conclusions: CRSCE-based de-escalation training would be useful to reduce the use of PR and the unexpected event caused by PR in psychiatric hospitals. The modules of CRSCE-based de-escalation training can be adopted for future intervention minimizing clinical use of PR. Clinical Trial Registration: This study was registered at Chinese Clinical Trial Registry (Registration Number: ChiCTR1900022211).

Recognition and management of agitation in acute mental health services: a qualitative evaluation of staff perceptions

BACKGROUND

Agitation among patients is a common and distressing behaviour across a variety of health care settings, particularly inpatient mental health. Unless recognised early and effectively managed it can lead to aggression and personal injury. The aim of this paper is to explore the experiences of mental health nurses in recognising and managing agitation in an inpatient mental health setting and the alignment of these experiences with best practice and person-centred care.

METHODS

This study used a descriptive qualitative methodology. Semi-structured focus group interviews were conducted with 20 nurses working in a mental health unit in 2018. Nursing staff described their experiences of assessing and managing agitation. Descriptive and Thematic Analysis were undertaken of the transcribed focus group dialogue.

RESULTS

Nurses combined their clinical knowledge, assessment protocols and training with information from patients to make an individualised assessment of agitation. Nurses also adopted an individualised approach to management by engaging patients in decisions about their care. In keeping with best practice recommendations, de-escalation strategies were the first choice option for management, though nurses also described using both coercive restraint and medication under certain circumstances. From the perspective of patient-centred care, the care provided aligned with elements of person-centred care nursing care.

CONCLUSION

The findings suggest that clinical mental health nurses assess and manage agitation, with certain exceptions, in line with best practice and a person-centred care nursing framework.

The Impact of Mental Illness Stigma on Psychiatric Emergencies

Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention. They are associated with feelings of fear, anger, prejudice, and even exclusion. The attitudes of professionals and factors related to the workplace culture in health can help to perpetuate stereotypes and interfere with the quality of care. Stigma has undesirable consequences in patients with mental disorders. Certain measures can reduce stigma and provide a more dignified way for patients to recover from the crisis. This article aims to discuss the causes of stigma, ways of dealing with it, and achievements that have been made in psychiatric emergency care settings.