Being restrained: a study of power and powerlessness

Patients' and staff members' experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis

BACKGROUND

Recent guidance has called for the reduction of restrictive practice use owing to growing concerns over the harmful physical and psychological effects for both patients and staff. Despite concerns and efforts, these measures continue to be used regularly to manage challenging behaviour in psychiatric in-patient settings.

AIMS

To undertake a systematic review of patients' and staff members' experiences of restrictive practices in acute psychiatric in-patient settings.

METHOD

A systematic review and thematic synthesis was conducted using data from 21 qualitative papers identified from a systematic search across three electronic databases (PsycInfo, Embase and MEDLINE) and citation searching. The protocol for the review was pre-registered on PROSPERO (CRD42020176859). The quality of included papers was examined using the Critical Appraisal Skills Programme (CASP).

RESULTS

Four overarching themes emerged from the experiences of patients: the psychological effects, staff communication, loss of human rights and making changes. Likewise, the analysis of staff data produced four themes: the need for restrictive practices, the psychological impact, decision-making and making changes. Patient and staff experiences of restrictive practices were overwhelmingly negative, and their use carried harmful physical and psychological consequences. Lack of support following restraint events was a problem for both groups.

CONCLUSIONS

Future programmes seeking to improve or reduce restrictive practices should consider the provision of staff training covering behaviour management and de-escalation techniques, offering psychological support to both patients and staff, the importance of effective staff-patient communication and the availability of alternatives.

Spanish mental health nurses' experiences of mechanical restraint: A qualitative descriptive study

WHAT IS KNOWN ON THE SUBJECT?: Mechanical restraint is a common practice in mental healthcare settings in Spain, despite controversy. Mechanical restraint is perceived as a negative experience for nurses and service users. Mechanical restraint damages the nurse-patient therapeutic relationship, which is essential in providing quality care and promoting recovery. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The negative experiences of service users and mental health nurses arising from use of mechanical restraint affects both parties involved and results in trauma. Using mechanical restraint can provoke a moral injury in mental health nurses which can negatively impact on the establishment of trust within the therapeutic nurse-patient relationship. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses must be aware of the negative effects that mechanical restraint use has on both their practice and their day-to-day lives. Post-mechanical restraint debriefing is required to repair the damage to the trust aspect of the nurse-patient relationship. Involving service users in co-producing a debriefing framework may be a way to rebuild trust through constructive dialogue.

ABSTRACT

INTRODUCTION: Mechanical restraint is an intervention that causes harm to service users and nurses, yet continues to be used in many countries, including Spain. However, there is a lack of research exploring Spanish mental health nurses' experiences of using mechanical restraint.

AIM

To describe the experiences of mental health nurses who have used mechanical restraint in practice.

METHODS

A qualitative descriptive methodology was used and a purposive sample of 10 Spanish mental health nurses were interviewed about their experiences of using mechanical restraint. Thematic analysis was then employed to analyse interview data.

RESULTS

Participants' experiences of using mechanical restraint were mostly negative. Three main themes arose from the analysis of interview transcripts, (i) symmetrical trauma, (ii) moral injury and (iii) broken trust.

DISCUSSION

The use of restrictive practices, which can be perceived as counter-therapeutic, exposes nurses to risks such as moral injury and service users to broken trust in the therapeutic nurse patient relationship. Avoiding empathy in order to use mechanical restraint is counterproductive, in the understanding that empathy is key to reducing this intervention.

IMPLICATIONS FOR PRACTICE

Reducing or eliminating use of mechanical restraints should be a policy and practice priority due to the symmetrical harms it causes both nurses and service users. The trust aspect of the therapeutic nurse-patient relationship is a significant casualty when mechanical restraint is used, therefore involving service users in co-production of post-mechanical restraint debriefing can be an avenue for restoring this trust through dialogue.

Women's experiences of restrictive interventions within inpatient mental health services: A qualitative investigation

Restrictive interventions (RI), such as physical restraint, seclusion, and rapid tranquilization, can have negative psychological effects on service users; however, there has been little investigation regarding their effects on women. The aim of this paper was to explore women's experiences of RI within UK inpatient mental health services. Twenty women accessing inpatient mental health services participated in semi-structured interviews. Using thematic analysis (TA), three primary themes were reported from women's experiences: (1) powerlessness, (2) dehumanization, and (3) relationships and communication. Clinical recommendations included ensuring gender-awareness and trauma-informed care training is mandatory for all mental health staff, for RI training to include awareness of gender differences, and for policies to be reviewed with regard to women being invasively searched and ensuring sanitary products are safely available for women within seclusion. Directions for future research include investigating the experiences of RI for women from minority ethnic groups and exploring important moderators and mediators in the relationship between RI and re-traumatization for women.

Heideggerian structures of Being-with in the nurse-patient relationship: modelling phenomenological analysis through qualitative meta-synthesis

Heideggerian philosophy is frequently chosen as a philosophical framing, and/or a hermeneutic analytical structure in qualitative nursing research. As Heideggerian philosophy is dense, there is merit in the development of scholarly resources that help to explain discrete Heideggerian concepts and to uncover their relevance to contemporary human experience. This paper uses a meta-synthesis methodology to pool and synthesise findings from 29 phenomenological research reports on Being-with in the nurse-patient relationship. We firstly considered and secured the most relevant Heideggerian elements to nurse-patient Being-with (Dasein-with, circumspection, solicitude, and discourse). Under these deductive codes, we then inductively developed sub-themes that seemed to explain the multifaceted nature of Being-with, through a secondary analysis and synthesis of published data from 417 patient, carer and nurse participants. Dasein-with was enhanced when nurses had first-hand experience with a phenomenon. Nurses moved between the inauthentic they-mode (task-orientated busyness, existential abandonment, rough handling and deficient modes of concern in potentially violent encounters), and the authentic self-mode (seeking connection [knowing], and openness [unknowing], which exposed their emotional vulnerability). Through circumspection (making room for, deseverance and directionality), technology and people were encountered environmentally feeding into nursing attention, assessment and communication. Nursing as a social arrangement (solicitude) was expressed through either leaping-in care (also perceived as 'power over') or leaping-ahead care (moving the patient towards independence). There was a place for both inauthentic (idle talk) and authentic discourse (including non-verbal and spiritual discourse) that nurses wove through the ontic everydayness of nursing tasks.

Forensic psychiatric patients' perceptions of situations associated with mechanical restraint: A qualitative interview study

To reduce the use and duration of mechanical restraint in forensic settings and ensure evidence-based patient care, we need more knowledge about patients' subjective experiences and perceptions. The aim was to investigate forensic psychiatric patients' perceptions of situations associated with the use of mechanical restraint and what they perceive as factors impacting the use and duration of mechanical restraint. Twenty participants were interviewed. Four themes were identified through a thematic analysis: 'overt protest reactions', 'silent protest reactions', 'illness-related behaviour', and 'genuinely calm', which together characterize patients' perceptions of their ways of acting and reacting during mechanical restraint episodes. These themes are linked together in two patterns in the process of mechanical restraint: 'pattern of protest' and 'pattern of illness'. Further research is needed to illuminate the associations between patients' perceptions of being subjected to mechanical restraint and ways of acting and reacting through the process of mechanical restraint.

Convergence and divergence: An analysis of mechanical restraints

BACKGROUND

Psychiatric nurses are regularly confronted with the uses and effects of control interventions such as mechanical restraints. Although there are evident tensions in the literature regarding the use of mechanical restraints, very little research has focused on the lived and embodied experience of their use, whether from the patient's perspective or the perspective of nursing staff responsible for their application.

RESEARCH AIMS

(1) to gain access to the bodily phenomenon of being placed in mechanical restraints; (2) to give voice to the intimate experiential understanding of this experience; and (3) through phenomenological interpretation, to understand the subjective processes and meaning-making of this experience.

RESEARCH DESIGN

For this research, we adopted a distinctly ethics-oriented application of the methodology known as interpretative phenomenological analysis, that is, the interpretive dimension of the research focused on ethical practice in mental healthcare - one that is informed by experiential accounts of the lived body.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 40 in-depth semi-structured, nondirected interviews with both nurses (n = 21) and patients (n = 19) we conducted to meet the aims of this article. Participants were recruited from an inpatient psychiatric unit of a Canadian general hospital.

ETHICAL CONSIDERATIONS

The research received research ethics board clearance from both the hospital where the study took place and the University of Ottawa.

FINDINGS

The comparative analysis is presented under the following headings: (1) context of care, (2) meaning of quality of care, (3) emotional reactions and nurse-patient relationship, (4) meeting the needs and (5) need for alternatives.

DISCUSSION/CONCLUSIONS

The research findings are discussed in light of current literature and implications for practice.

Coping with Violence in Mental Health Care Settings: Patient and Staff Member Perspectives on De-escalation Practices

This multiple case study explored de-escalation processes in threatening and violent situations based on patients and staff members perspectives. Our post hoc analysis indicated that de-escalation included responsive interactions influenced by the perspectives of both patients and staff members. We assembled their perspectives in a mental model consisting of three interdependent stages: (1) memories and hope, (2) safety and creativity and (3) reflective moments. The data indicated that both patients and staff strived for peaceful solutions and that a dynamic and sociological understanding of de-escalation can foster shared problem solving in violent and threatening situations.

A Co-operative Inquiry Into Generating, Describing, and Transforming Knowledge About De-escalation Practices in Mental Health Settings

De-escalation is concerned with managing violent behaviour without resorting to coercive measures. Co-operative Inquiry provided the conceptual basis for generating knowledge regarding de-escalation practices in acute mental health care settings. The research included service users and staff members as co-researchers and knowledge was generated in dynamic research cycles around an extended epistemology of knowing: experiential, presentational, propositional, and practical. Through this process, co-researchers became de-escalation learners, implementing de-escalation practices while transforming violence management. Neighbouring mental health communities' involvement strengthened the transformation process and assisted in validating the research results.

Perceptions of supported and unsupported prone-restraint positions

WHAT IS KNOWN ON THE SUBJECT?: Although the use of prone restraint should be avoided, it may remain a last resort emergency intervention for violent behaviour in psychiatric settings. However, when used as a last resort, concerns remain about the ability of staff to maintain the dignity, welfare and safety of the patient and minimize the potential adverse outcomes associated with restraint. This study builds on existing research regarding the risks of prone restraint by focusing on the psychological perceptions of individuals held in this position. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Individuals, who were asked to rate the psychological impact of two different prone-restraint positions (Supported and Unsupported Prone Positions) reported that the Supported Prone Position was more comfortable, less anxiety inducing and less limiting to breathing. Although no individual found prone restraint a positive experience, it shows that individuals found the psychological impact of the Supported Prone Position was less than the Unsupported Prone Position. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health professionals have a clear responsibility to maintain the dignity, safety and wellbeing of individuals subject to prone restraint as a short-term emergency procedure for the management of violent behaviour. Reducing both the physiological and psychological impact of prone restraint will help to reduce any adverse impact on individuals subject to such interventions. The findings will help influence current practice and promote the removal of the USPP as a specific prone-restraint intervention.

ABSTRACT

Aim Restraint-related deaths are multi-factorial with prone restraint remaining a concern due to the physiological and psychological risks. This study builds on evidence presented by (Barnett et al. Medicine, Science and the Law (2012b): 1) that the Supported Prone Position (SPP) reduces physiological risks, by examining if the SPP also reduces the psychological impact of prone restraint. Methods Twenty participants ran to near maximal exertion before being held in two prone-restraint positions: SPP and Unsupported Prone Position (USPP). Perceptions of comfort, anxiety and breathing limitation were measured using Visual Analogue Scales. Results Results showed that (1) comfort was 23% greater in the SPP; (2) anxiety was 55% less in the SPP; and (3) perception of breathing limitation was 32% less in the SPP when compared with the USPP. Negative perceptions expressed for the USPP included feeling trapped, vulnerable and concern over heart rate. Discussion In addition to reducing physiological risks, this study shows that the SPP reduced the psychological impact of prone restraint compared to USPP. Implications for Practice Settings where prone restraint cannot be avoided should remove the USPP as an emergency procedure in favour of the SPP as a way of maintaining safety and reducing the psychological impact of prone restraint.

Exploring the views of people with mental health problems' on the concept of coercion: Towards a broader socio-ethical perspective

In mental health care, coercion is a controversial issue that has led to much debate and research on its nature and use. Yet, few previous studies have explicitly explored the views on the concept of coercion among people with first-hand experiences of being coerced. This study includes semi-structured focus-groups and individual interviews with 24 participants who had various mental health problems and experiences with coercion. Data were collected in 2012-2013 in three regions of Norway and analysed by a thematic content analysis. Findings show that participants had wide-ranging accounts of coercion, including formal and informal coercion across health- and welfare services. They emphasised that using coercion reflects the mental health system's tendency to rely on coercion and the lack of voluntary services and treatment methods that are more helpful. Other core characteristics of coercion were deprivation of freedom, power relations, in terms of powerlessness and 'counter-power,' and coercion as existential and social life events. Participants' views are consistent with prevailing theories of coercion and research on perceived coercion. However, this study demonstrates a need for broader existential and socio-ethical perspectives on coercion that are intertwined with treatment and care systems in research and practice. Implications for mental health policy and services are discussed.

Understanding Mental Health Service User Experiences of Restraint Through Debriefing: A Qualitative Analysis

OBJECTIVE

To examine debriefing data to understand experiences before, during, and after a restraint (seclusion, chemical, and physical) event from the perspective of inpatients at a large urban mental health and addiction hospital.

METHOD

Audits were conducted on a purposeful sample of inpatient charts containing post-restraint event inpatient debrief forms (n = 55). Qualitative data from the forms were analyzed thematically.

RESULTS

Loss of autonomy and related anger, conflict with staff and other inpatients, and unmet needs were the most common factors precipitating restraint events. Inpatients often reported that increased communication with staff could have prevented restraint. Inpatients described having had various negative emotional states and responses during restraint events, including fear and rejection. Post-restraint, inpatients often desired to leave the unit for fresh air or to engage in leisure activities.

CONCLUSIONS

To our knowledge, our study is the first to use debriefing form data to explore mental health inpatients' experiences of restraint. Inpatients view restraint negatively and do not experience it as a therapeutic intervention. Debriefing, guided by a form, is useful for understanding the inpatient's experience of restraint, and should be used to re-establish the therapeutic relationship and to inform plans of care. In addition, individual and collective inpatient perspectives should inform alternatives to restraint.

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.

The relationship between attitudes towards different containment measures and their usage in a national sample of psychiatric inpatients

The aims of this report were to explore the relationships between patients' approval of containment measures, their levels of usage and patients' individual experience of each measure. Additionally the psychometric properties of the Attitudes to Containment Measures Questionnaire (ACMQ) were tested. A cross-sectional design was used. The ACMQ was completed by 1361 patients across 136 acute psychiatric wards from three regions in England that participated in the 'City 128' study. Staff on each ward completed the Patient-Staff Conflict Checklist - Shift Report at the end of each shift to log how often each containment measure was used. Frequency of patient reported containment correlated with rates reported by staff. Patients had separate attitudes to each containment measure rather than an attitude towards containment in general. High frequency of coerced intramuscular (IM) medication use was associated with negative attitudes to nearly all types of containment. The ACMQ has good construct validity. In wards where high levels of IM medication are used, all patients have lower approval ratings for a number of other containment measures. This suggests that IM medication has a negative impact not only on those subjected to it but also patients who witness it. Measures to reduce the negative impact of IM medication are discussed.

Attitudes to coercion at two Norwegian psychiatric units

BACKGROUND

Many countries allow for the use of restraint and seclusion in emergencies with psychiatric inpatients. Authors have suggested that the attitudes of staff are of importance to the use of restraint and seclusion.

AIM

To examine the attitudes to coercion at two Norwegian psychiatric units. In contrast to the idea that attitudes to coercion vary much within and between institutions, we hypothesized that staff's attitudes would be quite similar.

METHODS

We distributed a questionnaire to staff at two psychiatric units in two Norwegian counties. Eight wards were included. The questionnaire contained fictitious case histories with one patient that was violent and one patient that was self-harming, and staff were asked to describe how they would intervene in each emergency. Emergency strategies were sorted according to degree of restrictiveness, from the highly restrictive (restraint, seclusion) to the unrestrictive (talking, offering medication). Data were analysed with regression analyses.

RESULTS

There was only a limited degree of variance in how staff at the different units and various groups of staff responded. Staff were more likely to favour a highly restrictive intervention when the patients were physically violent. Male staff and unskilled staff were significantly more prone to choosing a highly restrictive intervention.

CONCLUSIONS

Our hypothesis was confirmed, as there was a limited degree of variance in staff's responses with respect to degree of restrictiveness. The study supported the idea that a range of different interventions are used in emergency situations.

Perspectives on the experience of being physically restrained: an integrative review of the qualitative literature

Publications providing information on the safe use of physical restraints, guidelines for restraint use, and journal articles on the care of mental health patients are frequently devoid of information regarding patients' perspectives on physical restraint. As physical restraint is a common procedure in many settings, the purpose of this review is to examine and summarize the qualitative literature on patients' perspectives on being physically restrained, from 1966 through to 2009. A formal integrative review of existing qualitative literature on patients' perspectives of physical restraint was conducted. Studies were critiqued, evaluated for their strength, and analysed for key themes and meanings. Twelve studies were ultimately identified and included in the review. Four themes emerged from the review, including negative psychological impact, retraumatization, perceptions of unethical practices, and the broken spirit. While little qualitative research on patients' perceptions of physical restraint exists, findings within the current literature reveal serious implications for patients and nurses alike. Additional research into physical restraint implications for the patient-nurse dyad is needed, and nurses should approach the use of physical restraint with caution and awareness of their potential psychological impact.

A review of interventions to reduce mechanical restraint and seclusion among adult psychiatric inpatients

This review examines the nature and effectiveness of interventions to reduce the use of mechanical restraint and seclusion among adult psychiatric inpatients. Thirty-six post-1960 empirical studies were identified. The interventions were diverse, but commonly included new restraint or seclusion policies, staffing changes, staff training, case review procedures, or crisis management initiatives. Most studies reported reduced levels of mechanical restraint and/or seclusion, but the standard of evidence was poor. The research did not address which programme components were most successful. More attention should be paid to understanding how interventions work, particularly from the perspective of nursing staff, an issue that is largely overlooked.

Restraints and the code of ethics: An uneasy fit

This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.

'It's part of the job, but it spoils the job': a phenomenological study of physical restraint

This paper examines mental health nurses' experiences of physical restraint in an acute inpatient psychiatric setting using Van Manen's descriptive hermeneutic phenomenological methodology. The aim was to understand the nurses' experiences of physical restraint. One overarching theme emerged from the analysis: It's part of the job. This theme had a subtheme of Control which was constituted by the Conflicted Nurse and the Scared Nurse. The findings suggest that mental health nurses are very uncomfortable with physical restraint despite it being taken-for-granted as integral to their role. The nurses experienced conflict and fear associated with the procedure and would prefer to utilize other de-escalation skills if it was possible. The main source of conflict related to the imperative to maintain control and the professional values of the therapeutic relationship. While the nurses could see no viable alternative in some situations, the paper concludes that while environmental issues impact on the practice of physical restraint mental health nurses need to practice it with as much care and humanity as possible.

Measuring adverse outcomes in inpatient psychiatry: the reliability of nurse recall

Nurses have been used in studies to report on quality-of-care issues and may be the most feasible sources of information about adverse outcomes. To date, however, the use of nurses to recall adverse outcomes of inpatient psychiatric care has not been examined systematically. The purpose of this study was to determine the reliability of psychiatric nurses' recall of physical restraint episode(s) (PRE) and assaultive/aggressive episode(s) (A/AE) and to describe the factors that influence recall. The study design was prospective and retrospective, and used a convenience sample of 36 nurses from a psychiatric hospital located in a large eastern city. Despite differences in nurse characteristics, perceptions of shift conditions, and organizational characteristics, nurse recall of PRE and A/AE was reliable overall. The majority of nurses actually recalled the exact number of events they had prospectively reported. Furthermore, the period for recall (2 vs. 4 weeks) did not significantly affect the reliability of nurse recall. These results suggest that psychiatric nurses are reliable informants of adverse outcomes. Lacking readily accessible and systematically reported data on PRE and A/AE, nurses may be the most feasible sources of information for these outcomes of inpatient psychiatric treatment. Future research should replicate these findings in other psychiatric treatment settings.

Changes in the occurrences of coercive interventions and staff injuries on a psychiatric intensive care unit

The purpose of this study was to compare the occurrences of coercive interventions and violence-related staff injuries before and after a 2-year violence prevention intervention on a psychiatric intensive care unit. The intervention aimed to improve nursing care by addressing patient violence from multiple perspectives. During the study, the unit was reorganized toward a higher concentration of severely disturbed patients. The results showed an increased proportion of coercive interventions without a corresponding increase in staff injuries. Use of coercive interventions is discussed in relation to a safe environment for both patients and staff.

On conflict, containment and the relationship between them

A programme of research into conflict (e.g. violence, absconding, medication refusal) and containment (e.g. seclusion, special observation, physical restraint) in inpatient psychiatry has been under way at City University, London, UK, for the past 10 years. Recent research findings, plus the challenges posed by ongoing projects, have made apparent the need for greater clarity about the overarching concepts of 'conflict' and 'containment'. This paper pulls together research findings pertaining to this issue, and conducts a reasoned analysis of what common characteristics might underlie 'conflict' and 'containment'. It is concluded that these are patient threats to safety, and the staff maintenance of safety. Details are presented on the inclusions and exclusions that follow from taking such a position, and potential definitions offered. On the grounds of this conceptual analysis, plus evidence for moderate degrees of statistical association between behaviours and events in each domain, it is concluded that it is legitimate to conduct analyses at the level of total conflict and containment rates, as well as at the level of individual types of behaviours and events (e.g. verbal abuse, sedation). Some of the mathematical difficulties in the analysis of total conflict and containment are addressed, and results of a weighting exercise presented. This exercise challenges our perception of the severity of some containment measures that are becoming more commonly used in acute psychiatry.

An analysis of nurses' post-incident manual restraint reports

Manual restraint techniques are associated with the management of violence in psychiatric settings. Restraint effectiveness and acceptability are under scrutiny, yet the nature and frequency of who or what were involved in restraint episodes have not previously been fully described or understood. The aim of this study was to describe the nature and frequency of manual restraint-related events and their components. This study was carried out using content analyses of nurses' post-incident reports from a psychiatric unit situated within a general hospital, and from its associated medium-secure unit. Requests for restraint occurred at the rate of about once per day, and the majority related to patients' ill-directed frustration, resistance to containment and their desire to leave the ward. Only half of responses to conflicts resulted in restraint implementation. The majority of restraint activities occurred during the afternoon and night. Male patients and detained patients were more frequent participants in restraint interventions. To a lesser extent, police, ambulance, fire services, hospital security, visitors and ex-patients were also involved in restraint episodes. Injuries were rare. In conclusion, training in restraint skills, clinical audit of adverse incidents, and research into psychiatric aggression all need to take into account the association of restraint with the enforcement of detention and treatment of acutely ill patients. The coupling of restraint with medication requires examination of its safety and efficacy. Interagency training may enable the essential services involved to coordinate restraint activities more effectively.

The conceptualization of physical restraint as a nursing-sensitive adverse outcome in acute care psychiatric treatment settings

The occurrence of physical restraint episodes in psychiatric settings is a major public health issue because the therapeutic utility of this form of behavior control has not been substantiated empirically. The purpose of this article was to examine the extant literature to determine if evidence supports the conceptualization of a physical restraint episode as an adverse client outcome that is sensitive to the organization of nursing care in psychiatric settings. An adapted version of the Quality Health Outcomes Model (Mitchell, P. H., Ferketich, S., & Jennings, B. M. (1998). Quality Health Outcomes Model. Image Journal of Nursing Scholarship, 30, 43-46) was used as the conceptual model to guide this inquiry. The databases Cumulative Index to Nursing and Allied Health Literature, Health and Psychosocial Instruments, HealthSTAR/Ovid and Healthstar, Medline, and psychINFO were searched from 1990 to 2005. There are 101 sources in this review. Evidence strongly suggests that a physical restraint episode is an adverse outcome that is sensitive to the organization of nursing care. A systematic exploration of the specific structures and processes of the organization that affect adverse outcomes, such as physical restraint episodes, is lacking in the United States.

Psychiatric inpatients' perceptions of positive and negative aspects of physical restraint

This qualitative study explored the experiences and feelings of psychiatric inpatients concerning their first encounter with physical restraint. Its purpose was to determine whether restraint has any other effects, other than the intended one of protection. Thirty psychiatric inpatients who had experienced physical restraint in two acute admission wards within the previous two days, were interviewed by the principal researcher. About two-thirds of the participants expressed positive feelings towards staff who had shown concern about their needs and had been willing to help. Positive therapeutic effects, other than physical protection, were largely related to the caring attitudes and behavior demonstrated by the staff. Negative effects were related to the inability of staff to satisfy patients' needs for: concern, empathy, active listening, and information about restraint during and after its use. The conclusion of the study was that physical restraint could be a therapeutic intervention when health professionals were able to provide psychological and informational support to patients throughout the procedure. A perceived unsatisfactory caring attitude and behavior by the restraint provider would cause negative feelings in the patient and would be more likely to result in the patient struggling physically with the restrainer. Additional physical and psychological harm would also be experienced by patients in these circumstances.

Empowerment of individuals with enduring mental health problems: results from concept analyses and qualitative investigations

Empowerment has been proposed to enhance the well-being of individuals with enduring mental health problems. Despite this apparent endorsement, critics charge that the concept of empowerment is poorly defined, and its actualization within mental health care is rare. Concept analyses and findings from qualitative research offer helpful insights into the process of empowerment and ways to promote it among individuals with long-term mental health problems. An empowerment model is proposed based on concept analyses, which are supported by qualitative findings.

Mesures de contrôle en milieu psychiatrique : trois perspectives pour en guider la réduction, voire l’élimination

Cet article présente dans un premier temps, le contexte dans lequel se situent les orientations ministérielles en matière de mesures de contrôle en psychiatrie telles la contention et l’isolement. Les auteurs exposent les connaissances concernant l’utilisation et la réduction des mesures et proposent trois perspectives pour en guider la réduction et l’élimination. La première perspective est orientée vers le contrôle de l’agir violent, la seconde, guidée par une meilleure compréhension de l’expérience vécue par les acteurs impliqués dans l’agir violent. La troisième perspective proposée par les auteurs est dirigée vers l’intégration du traumatisme comme expérience et prend en compte les différentes dimensions du cycle de la violence auquel contribuent les mesures de contrôle. Enfin, les auteurs concluent sur des pistes d’intervention pour réduire, sinon éliminer les mesures de contrôle en psychiatrie.

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].

Staff's attitudes to the use of restraint and seclusion in a Norwegian university psychiatric hospital

A questionnaire-based study examining the experiences and attitudes of staff to restraint and seclusion in a Norwegian university psychiatric hospital demonstrated that a majority of staff believed the interventions were used correctly. Staff at wards with high usage of restraint and seclusion, and male staff, were most critical to how often the interventions were used. Most staff favoured the use of physical restraint, although they believed it was the intervention patients were least favourable to. Highly educated staff were not more critical to the use of restraint and seclusion than other staff. Despite the fact that a majority of staff believed that using restraint and seclusion made patients calmer and did not cause aggression, anxiety or injuries, about 70% had been assaulted by patients in connection with the interventions. Many staff believed the use of restraint and seclusion violated patients' integrity, could harm the provider-patient alliance and could frighten other patients. Violence, self-harm and threats were given as main reasons for the use of restraint. Increased staffing and more attention by level-of-care staff were cited as the most important strategies for reducing the use of restraint and seclusion. There is a need for informing all staff about the negative effects of restraint and seclusion and for training staff in less restrictive ways in dealing with aggressive and violent patients.

Nursing Staff's Attitudes Toward Seclusion & Restraint

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.