Physical restraint in mental health services: a gap in the knowledge regarding this extreme manual handling task

"It's not a nice thing to do, but…": A phenomenological study of manual physical restraint within inpatient adolescent mental health care

AIM

To explore nursing staff's experiences of using manual (physical) restraint within inpatient adolescent mental health care.

DESIGN

This was a descriptive phenomenological study.

METHODS

Individual semi-structured interviews were conducted with 12 nursing staff between March 2021 and July 2021. The nursing staff were recruited from four inpatient adolescent mental health hospitals across three National Health Service Trusts in England. Interviews were transcribed verbatim and analysed using Braun and Clarke's reflexive approach to thematic analysis.

RESULTS

Four themes were generated from the analysis: (1) it needs to be done sometimes; (2) it's not a nice thing to do; (3) it does not really damage the therapeutic relationship; and (4) importance of team support. Despite strongly reporting that it was sometimes necessary to manually restrain young people for substantial safety reasons, participants spoke with dislike about its use, and described consequential aversive experiences of emotional distress, patient aggression, pain and injury, and physical exhaustion. Participants reported relying on each other for emotional and practical support. Three participants reported observing premature restraint use by non-permanent staff.

CONCLUSION

The findings detail a paradoxical picture of the nursing staff's experiences where restraint is experienced as psychologically and physically aversive yet deemed as sometimes necessary to prevent significant harm.

REPORTING METHOD

The Standards for Reporting Qualitative Research (SRQR) checklist was used to guide reporting.

IMPACT

This study suggests a need for the targeting of non-permanent staff for restraint minimization interventions, and highlights how the treatment of non-permanent staff by permanent staff may contribute to avoidable restraint practices. The findings indicate several ways in which the staff-young person therapeutic relationship can be preserved in the context of restraint. However, this needs to be treated with caution given that young people's voices were missing from this study.

PATIENT OR PUBLIC CONTRIBUTION

This study focused on nursing staff's experiences.

Healthcare staff's experiences of using manual physical restraint: A meta-synthesis review

Manual restraint is a hands-on type of physical restraint used to prevent harm to service users and staff, and to administer necessary treatments. This article reports on a review and meta-synthesis of the qualitative literature on healthcare staff's experiences of using manual restraint. Three electronic databases (CINAHL Complete, MEDLINE, and PsycINFO) were systematically searched, and 19 studies were included. Thematic synthesis was used to synthesize the findings. The Critical Appraisal Skills Programme (CASP) checklist was used to appraise study quality. The synthesis generated one overarching interpretive theme, "unpleasant but necessary," and five subthemes: "maintaining safety triumphs all," "emotional distress," "significance of coping," "feeling conflicted," and "depletion." Seven studies indicated that, from staff perspectives, manual restraint was not always used as a last resort. Healthcare staff experience manual restraint as a psychologically and physically unpleasant practice, yet paradoxically deem its use to be sometimes necessary to keep themselves and service users safe from harm. The findings indicate a need for healthcare staff support, post-restraint debriefing meetings with service users, and the implementation of manual restraint minimization programs in healthcare settings.

Nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa

Manual restraint, a type of physical restraint, is a common practice in inpatient mental health settings linked to adverse physical and psychological staff and patient outcomes. However, little is known about the use of manual restraint for compulsory nasogastric feeding of patients with anorexia nervosa within inpatient eating disorder settings. The present phenomenological study aimed to explore nursing assistants' experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. The study followed COREQ guidelines. Eight semi-structured interviews were conducted with eight nursing assistants from one UK inpatient child and adolescent eating disorder service. Interviews were transcribed verbatim and analysed using thematic analysis. Three themes were extracted: An unpleasant practice, importance of coping, and becoming desensitized and sensitized. Nursing assistants commonly experienced emotional distress, physical exhaustion, physical injury and physical aggression as a result of their manual restraint use. Nursing assistants appeared to cope with their distress by talking with colleagues and young persons who were further in their recovery, and by detaching themselves during manual restraint incidents. The findings highlight that the use of manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa in the UK is a highly distressing practice for nursing assistants. It is therefore important that sufficient supervision, support, and training are made available to staff working in these settings.

Human factors in mental healthcare: A work system analysis of a community-based program for older adults with depression and dementia

Mental healthcare is a critical but largely unexplored application domain for human factors/ergonomics. This paper reports on a work system evaluation of a home-based dementia and depression care program for older adults, the Aging Brain Care program. The Workflow Elements Model was used to guide data collection and analysis of 59 h of observation, supplemented by key informant input. We identified four actors, 37 artifacts across seven types, ten action categories, and ten outcomes including improved health and safety. Five themes emerged regarding barriers and facilitators to care delivery in the program: the centrality of relationship building; the use of adaptive workarounds; performance of duplicate work; travel and scheduling challenges; and communication-related factors. Findings offer new insight into how mental healthcare services are delivered in a community-based program and key work-related factors shaping program outcomes.

An analysis of patient safety incident reports describing injuries to staff working in critical care in the North West of England between 2009 and 2013

BACKGROUND

Critical care environments are potentially high-risk areas for staff harm due to procedural demand and increased incidence of delirium/dependence. The principal types of harm and temporal trends have not yet been quantified.

METHODS

Retrospective analysis of a multicentre dataset prospectively collected over a five-year period. All patient safety incidents reported to a regional network project were analysed; those recorded as staff harm were extracted, quantified and assessed by thematic analysis to identify key areas of harm, temporal trends and incident rates.

RESULTS

Staff harm accounted for 7% of all reported patient safety incidents over the study period. Incident rates remained static, ranging annually from 2.6 to 3.7 episodes/1000 patient days. Assaults on staff accounted for the highest proportional contribution on thematic analysis, which was a consistent annual finding. Sharps injuries and manual handling incidents were also notable contributions. Temporal trends for each theme remained static over the study period implying limited reduction in staff harm despite implementation of national guidance and local initiatives.

CONCLUSION

Staff harm is a consistent issue for those working in critical care. Assaults on staff appear to be the highest contributor on thematic analysis. These data imply significant reduction in harm can still be achieved and can be used to design and implement interventional measures.