Beyond restraint: Raising awareness of restrictive practices in acute care settings

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

A comprehensive examination of research instruments utilized for assessing the attitudes of healthcare professionals towards the use of restraints in mental healthcare: A systematic review

AIM

This systematic review aimed to identify, describe and evaluate questionnaires measuring health professionals' attitudes towards restraints in mental healthcare.

DESIGN

A systematic review was undertaken in accordance with the COSMIN protocol for systematic review and the relevant sections of the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

OVID Medline, OVID nursing, Psychinfo, Embase and Cinahl were systematically searched from databases inception, with an initial search in December 2021 and updated in April 2022.

REVIEW METHODS

The inclusion criteria compromised articles reporting on self-reported instruments of attitudes or perceptions, development or validation of instruments and the evaluation of one or more measurement properties. Articles using multiple instruments in one study or not published in English were excluded. Two researchers independently extracted the data and appraised the methodological quality using the COSMIN guidelines and standards (consensus-based standards for the selection of health measurement instrument). A narrative synthesis without meta-analysis was performed. The systematic review was registered in PROSPERO Protocol ID CRD42022308818.

RESULTS

A total of 23 studies reporting ten instruments were included. The findings revealed a broad variation in the content of the questionnaires, the use of terms/constructs and the context in which the various instruments measure attitudes towards coercive measures. Many studies lacked sufficient details on report of psychometric properties. Finally, the results were not summarized and the evidence not GRADED.

CONCLUSIONS

There is a need for updated and adapted instruments with origins in theory and clear joint definitions such that attitudes towards coercive measures can be reliably assessed regarding the validity and reliability of instruments, which will be of importance to facilitate the use of instruments in research and clinical settings.

IMPACT

Reviews addressing surveys, self-reported attitudes towards restraints in mental healthcare and examination of psychometric properties seem limited. We highlight distinct complexity, psychometric limitations and broad variation in the context and content measuring attitudes towards coercive measures, and their various use of terms/constructs in the existing questionnaires. These findings contribute to further research regarding the development of questionnaires and the need of representing the concept well - carefully denoted by the indicators, likewise the importance of applying questionnaires with properly reported measurement properties in terms of validity and reliability to ensure the use in research and clinical settings.

'No health without mental health': where are we now?

Mental health services are under unprecedented pressure with overwhelming referrals and a current waiting list of 1.2 million people of all ages. The cross-government White Paper 'No health without mental health' was launched 12 years ago detailing the importance of wellbeing services in the creation of mentally healthy communities through health promotion and illness prevention. While primary care, community services and psychiatry are pivotal in the treatment of mental Illness/disorder, mental health care per se is on a continuum, and a great deal of work can be undertaken in communities by wellbeing services to prevent avoidable referrals. This paper proposes a broad framework of education and training for wellbeing/positive mental health services, primary and community care, and nurses working in Community Mental Health Treatment Teams and Home Treatment Teams to ensure all those working with potentially vulnerable adults and children are regulated and meet national standards for mandatory mental health education and training.

'Stakeholders are almost always resistant': Australian behaviour support practitioners' perceptions of the barriers and enablers to reducing restrictive practices

A restrictive practice (RP) is defined as a practice or intervention that has the effect of restricting the rights or freedom of movement of a person, and includes physical, mechanical, and chemical restraint, and seclusion. If misused or overused, RPs may present serious human rights infringements. In Australia, behaviour support practitioners who deliver behaviour support funded by the National Disability Insurance Scheme are responsible for developing positive behaviour support plans that aim to reduce and eliminate the use of RPs. At present, little is known about the barriers that behaviour support practitioners experience when attempting to reduce and eliminate the use of RPs and, conversely, what helps (or enables) them to reduce and eliminate RPs. To learn more, we conducted an online survey consisting of two open-ended questions with 109 Australian behaviour support practitioners to identify barriers and enablers. We found that fear and reluctance on the part of stakeholders were often barriers to reducing the use of RPs. However, we found that having time, funding, and resources for training, supervision, other implementation activities, care team collaboration, and data-based decision-making helped overcome barriers. We provide specific recommendations for addressing identified barriers for individual behaviour support practitioners, service provider organisations, and government and regulatory agencies.

Coming to Grips-How Nurses Deal With Restlessness, Confusion, and Physical Restraints on a Neurological/Neurosurgical Ward

Physical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid under what circumstances physical restraints are applied harmlessly. The aim of this research was to understand how physical restraints are used by neurology/neurosurgery ward nurses in relation to the protocol. In ethnographic action research, the Functional Resonance Analysis Method (FRAM) was used to map and compare physical restraints as part of daily ward care against the protocol of physical restraints. Comparison between protocol and actual practice revealed that dealing with restlessness and confusion is a collective nursing skill vital in dealing with physical restraints, while the protocol failed to account for these aspects. Supporting and maintaining this skillset throughout this and similar nursing teams can prevent future misguided application physical restraints, offering valuable starting point in managing patient safety for these potentially dangerous objects.

Rapid tranquillisation: an issue for all nurses in acute care settings

The management of challenging behaviour, violence and aggression is not only an issue for mental health and learning disability nurses. Increasingly, nurses working in emergency departments (EDs), medical assessment units and general medical or surgical wards may encounter acts of challenging behaviour, violence and aggression on a regular basis. Restraint is sometimes used as a tool in the management of these patients; this may be in the form of physical, mechanical or chemical restraint. Rapid tranquillisation (RT) is often considered a form of chemical restraint, which may be used in an emergency situation when prescribed. If RT is given it should be done so as the least restrictive option, with intramuscular and intravenous administration as a last resort. Patient monitoring following administration is paramount. This article explores best practice in the administration of RT from a clinical perspective.

Reducing restrictive practice: a pertinent issue for children's services

The reduction of restrictive practice has gained momentum in mental health services and it is now becoming evident in mainstream adult services. There remains confusion as to the definition of 'restrictive practices' across all sectors of health care, including the difference between 'restrictive practices' (such as attitudes of control, limit setting and unnecessary ward rules) and 'restrictive interventions' (including physical, chemical or mechanical restraint). This article highlights the relevance of restrictive practice to children's nursing and argues that the principles apply across all health provision. Acts of restrictive practice may result in challenging behaviour, or even restrictive interventions, strategies to minimise both restrictive practice and subsequent acts of challenging behaviour are explored. Behavioural support plans adopting a bio-psycho-pharmaco-social approach have been shown to be effective in both mental health and adult nursing and are recommended for use in children's nursing.

Examining the Associations between Psychological Flexibility, Mindfulness, Psychosomatic Functioning, and Anxiety during the COVID-19 Pandemic: A Path Analysis

Social distancing plays a leading role in controlling the spread of coronavirus. However, prolonged lockdown can lead to negative consequences in terms of mental health. The goal of the research is to examine the relationship between anxiety and general psychosomatic functioning during the COVID-19 pandemic; the impact of psychological flexibility and mindfulness is also considered. Variables were measured with self-report questionnaires and symptom checklists. The sample included 170 people (M = 27.79, SD = 8.16). Pearson’s correlation, stepwise regression, and path analysis were conducted. The results showed a significant positive relationship between state anxiety and somatic and psychological responses to the pandemic. Path analysis revealed that mindfulness had a direct negative impact on and decreased the level of state anxiety (b = −0.22, p = 0.002), whereas psychological flexibility influenced the variable indirectly (b = 0.23, p = 0.002) by enhancing psychosomatic functioning (b = −0.64, p < 0.001). Psychological flexibility and mindfulness may mediate the development of mental disorders and facilitate achieving overall wellbeing. The study points to the usefulness of mindfulness practice as a form of self-help with anxiety symptoms; this is crucial during the pandemic because contact with clients is restricted.

Restraint use in the acute-care hospital setting: A cross-sectional multi-centre study

BACKGROUND

Restraints are likely to negatively affect patients' health and therefore a reduction in their usage is recommended for all health-care settings. To date, research on restrictive practices has concentrated on mental health and long-term care settings. In the acute-care hospital setting few studies have been published and these studies mainly focus on physical/mechanical restraints in specific subpopulations and/or on intensive care units. However, to ensure restraints are used as little as possible in the acute-care hospital setting, it seems important to investigate more comprehensively the use of restraints, to include all types of restraints irrespective of ward type or subpopulations and to identify factors associated with restraint use.

OBJECTIVE

The aim of this study was to investigate restraint use regardless of ward type in the acute-care hospital setting, including restraint type, reasons for restraint use, process indicators when using restraints and restraint use-associated patient characteristics.

METHODS

Using a cross-sectional multi-centre design, data were collected by means of an annual international prevalence measurement in acute-care hospitals in Switzerland and Austria. All hospitalised patients aged 18+ who gave informed consent were included. Data were collected at three measurement points between 2016 and 2018. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

A total of 29,477 patients hospitalised in 140 hospitals were included in this study. The prevalence rate for the use of at least one restraint over a 30-day period was 8.7% (n = 2577), with mechanical restraints representing the highest proportion of restraint type used (55.0%, n = 1417). The main reason for restraint use was fall prevention (43.8%, n = 1129), followed by confusion or delirious behaviour (20.4%, n = 525). In 64.3% of the cases (n = 1657), restraint use was documented in the patient file. Regular evaluation occurred in 42.9% of the cases (n = 1105). Care dependency had the strongest association with restraint use (odds ratio [OR] 25.00, 95% confidence interval [CI] 21.01-29.78 for completely dependant patients in comparison to completely independent patients), followed by mental and behavioural disorders (OR 2.36, 95% CI 2.15-2.59).

CONCLUSIONS

Restraints are often utilised in hospitals in complex care situations such as with patients at risk of falling or with delirium. When using restraints the consideration of processes like documentation and evaluation shows great potential for improvement. Standardisation of these processes and education of the interprofessional team could be beneficial for raising awareness and for the sustainable reduction of restraint use. Tweetable abstract: In hospitals restraints are often used in complex care situations. However, their use seems to be insufficiently documented and evaluated.

Nurses' behaviours towards physical restraint use in the ICU: A descriptive qualitative study

AIMS AND OBJECTIVES

The study aims to explore and describe nurses' behaviours towards physical restraint (PR) use in intensive care units (ICUs) and identify key characteristics of these experiences.

BACKGROUND

Patients within the ICU are always vulnerable, which requires a thoughtful deliberation when employing PR in ethically laden situations. Considering that the qualitative study on nurses' behaviours towards PR use in ICUs is limited, a deep understanding of how nurses reason and restrict patients is necessary before developing a minimizing programme in hospitals.

METHODS

A descriptive qualitative study was conducted in this paper. Data were collected by 24 semistructured, in-depth and individual interviews about PR, where 24 nurses were drawn from six ICUs of four hospital settings from a comprehensive tertiary care hospital in Qingdao. The QSR NVivo 11.0 software program was used to manage the interview data, and data analysis was guided by the Qualitative Analysis Guide of Leuven. The checklist of Consolidated Criteria for Reporting Qualitative Studies was followed as a guideline in reporting the study.

RESULTS

Regarding PR, nurses' behaviours start with a hazard perception, followed by hesitation about whether to restrict the patient. They would usually decide to apply PR when they think that no other choice to control the situation is available. Then, they would reflect on and rationalize their behaviours. Nurses, intensivists, patients and their families participate in and affect this process directly or indirectly.

CONCLUSIONS

Nurses' behaviours towards PR use comprise a series of complex processes centred on safety. Nurses' decision making should be performed with the participation of intensivists, patients and family caregivers.

Biopsychopharmacosocial approach to assess impact of social distancing and isolation on mental health in older adults

It is impossible to predict or comprehend the impact of the ongoing COVID-19 pandemic. The UK Government's advice for vulnerable people, including older adults, to move towards self-isolation and social distancing is likely to reduce rates of transmission, the risk of severe illness and the impact on the acute health services. Although justified and necessary, this process of isolation is likely to have a negative impact on the mental health of these vulnerable groups, especially older people. It will become increasingly important for community health professionals to assess subtle changes in older persons' mental health, as the duration of this period of isolation remains unclear. The biopsychopharmacosocial model provides one method of assessing mental health and planning health and social care needs. This article hopes to guide community health professionals through the specifics of this assessment model in relation to the growing COVID-19 pandemic.

Could therapeutic diaries support recovery in psychiatric intensive care?

Despite growing literature surrounding the use of patient diaries in intensive care units within general health care and the positive effects these may have on a patient's psychological recovery from such an admission, no studies exist examining the effects of similar patient diaries in psychiatric intensive care units when used with people experiencing an acute exacerbation of psychosis. This article hypothesises the potential positive effects of diaries kept for patients in psychiatric intensive care units. In the development of strategies to help people in psychiatric crisis understand and manage their own distress and psychological trauma, diaries may be helpful for the prevention of further psychological problems and aid recovery post discharge. Research is required to consider the possible effects of therapeutic diaries and the role of the multidisciplinary team in keeping these within psychiatric intensive care settings.

The use of positive behaviour support plans in mental health inpatient care: A mixed methods study

WHAT IS KNOWN ON THE SUBJECT?: There is a drive to use positive and proactive approaches to mental health care to reduce the use of restrictive practices such as seclusion and restraint. Positive behaviour support plans have been used successfully to do this in learning disability services, and in England, it is now a regulatory requirement that anyone with challenging behaviour should have an individualized behaviour support plan. However, positive behaviour support plans specifically have not been evaluated as part of routine mental health care and mental health nurses' and relatives' attitudes towards them are unknown. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This evaluation of positive behaviour support plans in routine mental health inpatient care found that they had not been widely implemented or completed as intended. Barriers to the use of the plans included confusion among nurses and relatives around the principles of positive behaviour support, including how, when and for whom the plans should be used, difficulties in being able to describe the function of a patient's behaviour and lack of engagement with relatives and patients. Nevertheless, nurses and relatives valued the plans, in particular for their potential to facilitate holistic care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: To use the plans successfully, mental health nurses will need training to understand fully the rationale behind the positive behaviour support approach and will need to engage more with relatives and patients. Commitment to the approach from the whole care team and organization will be needed to implement the plans consistently for all patients. Abstract Introduction An international drive is to minimize restrictive practices in mental health care. Positive behaviour support plans (PBSPs) help staff prevent behaviour which would require restrictive intervention. Originating in learning disability services, data within mental health care are limited. Aims To evaluate PBSPs within a mental health inpatient service; understand mental health nurses' and relatives' attitudes to them; and understand the barriers and facilitators for their use in routine mental health care. Methods Mixed methods-quality ratings and interviews with relatives and nurses. Results Positive behaviour support plans were poorly implemented. Relatives and nurses valued the potential of PBSPs to facilitate holistic care, though no relative had contributed to one and not every eligible patient had one. Barriers to their use included confusion around positive behaviour support, including how, when and for whom PBSPs should be used, and difficulties describing the function of a behaviour. Discussion The potential of PBSPs to improve mental health care is recognized. However, there are barriers to their use which should be addressed to ensure that PBSPs have been properly implemented before their impact on patient care can be assessed. Implications for practice Mental health professionals implementing PBSPs should engage with relatives and patients, gain organizational commitment and ensure that those involved understand fully the positive behaviour support approach.