Exploring psychiatric patient restraints: Balancing safety, ethics, and patient rights in mental healthcare

Restraint, often linked with limiting an individual's freedom of movement, has become a focal point of extensive discussion and evaluation within the realm of mental healthcare. Striking a delicate balance between ensuring individual safety and minimizing reliance on restraint methods poses a significant challenge. In mental health inpatient settings, the prevalent forms of restraint encompass physical, chemical, environmental, and psychological methods. Paradoxically, the consequences of employing restraint can be severe, ranging from injuries and cognitive decline to sedation and, in extreme cases, fatalities. This paper seeks to offer a nuanced exploration of the landscape surrounding psychiatric patient restraints, considering both global perspectives and specific insights from the Indian context. The guidelines outlined in India's Mental Healthcare Act of 2017, which governs the use of restraint on individuals suffering with mental illnesses, are also examined in detail.

Using Q-methodology to explore mental health nurses' knowledge and skills to use recovery-focused care to reduce aggression in acute mental health settings

When nurses practise recovery-focused care, they contribute positively to the consumer's mental health recovery journey and empower the person to be actively engaged in the management of their illness. While using recovery-focused care is endorsed in mental health policy, many health professionals remain uncertain about its application with consumers who have a risk for aggression during their admission to an acute mental health inpatient setting. This paper reports on Australian research using Q-methodology that examined the knowledge and skill components of recovery-focused care that nurses use to reduce the risk for aggression. The data from forty mental health nurses revealed five factors that when implemented as part of routine practice improved the recovery outcomes for consumers with risk of aggression in the acute mental health settings. These factors were as follows: (I) acknowledge the consumers' experience of hospitalization; (II) reassure consumers who are going through a difficult time; (III) interact to explore the impact of the consumer's negative lived experiences; (IV) support co-production to reduce triggers for aggression; and (V) encourage and support consumers to take ownership of their recovery journey. These findings provide nurses with a pragmatic approach to use recovery-focused care for consumers with risk for aggression and contribute positively to the consumers' personal recovery.

Resilience of auxiliary nurses providing nursing care to patients with intellectual disabilities at a public mental healthcare institution

Background

Although mental health is regarded by the International Council of Nurses as a very important element of wellness, healthcare to patients with intellectual disabilities still remains neglected and under-resourced in most societies. Auxiliary nurses are crucial in providing nursing care to patients with intellectual disabilities. These nurses may not be prepared to handle challenges in providing nursing care to these patients, but their resilience can help them to manage these challenges. Limited research is available with regard to the resilience of auxiliary nurses providing nursing care to patients with intellectual disabilities.

Objectives

To explore and describe the perceptions of auxiliary nurses providing nursing care to patients with intellectual disabilities on their resilience and protective mechanisms and vulnerability factors that influence their resilience when providing nursing care to these patients.

Method

A qualitative, descriptive inquiry approach was used. The population comprised approximately 220 auxiliary nurses providing nursing care to patients with intellectual disabilities at a mental healthcare institution. Auxiliary nurses were selected through purposive sampling with the assistance of a mediator. The sample size was determined by data saturation. The data were collected through four focus group interviews with altogether 32 participants.

Results

Five main themes emerged from the data. Practical wisdom was applied by the participants. They also made use of different forms of interactions, including the application of strategies such as utilising induction programmes and being willing to learn, in order to remain resilient. Protective mechanisms and vulnerability factors influence their resilience.

Conclusions

Recommendations to strengthen the resilience of auxiliary nurses caring for patients with intellectual disabilities were formulated from the research findings, including recommendations for nursing practice, education and nursing research. Informal peer support, as well as addressing ethical issues, improving nurse–patient communication, training to handle adverse working conditions, and continuing education and further research on the practical wisdom of auxiliary nurses, is recommended.

Students' Learning Experiences from Didactic Teaching Sessions Including Patient Case Examples as Either Text or Video: A Qualitative Study

OBJECTIVES

The aim of this study was to explore medical students' learning experiences from the didactic teaching formats using either text-based patient cases or video-based patient cases with similar content. The authors explored how the two different patient case formats influenced students' perceptions of psychiatric patients and students' reflections on meeting and communicating with psychiatric patients.

METHODS

The authors conducted group interviews with 30 medical students who volunteered to participate in interviews and applied inductive thematic content analysis to the transcribed interviews.

RESULTS

Students taught with text-based patient cases emphasized excitement and drama towards the personal clinical narratives presented by the teachers during the course, but never referred to the patient cases. Authority and boundary setting were regarded as important in managing patients. Students taught with video-based patient cases, in contrast, often referred to the patient cases when highlighting new insights, including the importance of patient perspectives when communicating with patients.

CONCLUSION

The format of patient cases included in teaching may have a substantial impact on students' patient-centeredness. Video-based patient cases are probably more effective than text-based patient cases in fostering patient-centered perspectives in medical students. Teachers sharing stories from their own clinical experiences stimulates both engagement and excitement, but may also provoke unintended stigma and influence an authoritative approach in medical students towards managing patients in clinical psychiatry.

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.

The Eileen Skellern Lecture 2014: physical restraint: in defence of the indefensible?

Aggression is reported to be prevalent in psychiatric inpatient care and its frequency towards healthcare professionals is well documented. While aggression may not be entirely avoidable, its incidence can be reduced through prevention and the minimization of restrictive practices such as physical restraint. The study aims to explore three common 'defences' to account for the use of physical restraint; to challenge each defence with regard to the evidence base; and to identify how services are responding to the challenge of reducing the use of restrictive interventions. Following a number of investigations to highlight serious problems with the use of physical restraint, it seems timely to examine its efficacy in light of the evidence base. In order to do this, three key defences for its use will be challenged using the literature. A combination of interventions to minimize the use of restraint including advance planning tools, and recognition of potential trauma is necessary at an organizational and individual level. Patients can be severely traumatized by the use of restrictive practices and there is a drive to examine, and reduce the use and impact of using these models that incorporate trauma informed care (TIC) and person centredness.

Causes and management of aggression and violence in a forensic mental health service: perspectives of nurses and patients

Nurses' attitudes about the causes and management of aggression affects their choice of intervention. We aimed to compare the attitudes held by patients and staff in a forensic mental health service with the Management of Aggression and Violence Attitudes Scale, and examine the factor validity of the tool in this setting by conducting a prospective comparative questionnaire survey. Staff (n = 72) and patient (n = 98) attitudes differed to a limited extent. Confirmatory factor analysis refuted the previously reported structure of the tool. Exploratory factor analysis suggested three underlying factors related to modifiability of aggression, hands on management, and hands off management. Patients were more optimistic than nurses about the modifiability of aggressive behaviour. Male patients and those with diagnoses other than personality disorder were significantly more likely to agree about modifiability than controls. Forensic inpatients recognize the need for the use of a range of techniques to prevent and manage aggression and violence, but selected groups are most likely to believe that aggression is modifiable. Prevention and management of aggression training should emphasize the modifiability of aggressive behaviour. The development of measures of modifiability and management style would assist in the evaluation of training and would offer new avenues for research.

Managing the risks of physical intervention: developing a more inclusive approach

Since psychiatry evolved as a professional discipline, mental healthcare professionals have had to, as a last resort, physically intervene to manage physically aggressive patients. In the United Kingdom, physical intervention techniques migrated from the prison service in the mid 1980s where there was extensive use of two particularly controversial practices; 'pain compliance' and the 'prone restraint position'. This paper examines how the classification of the 'prone restraint position' has led to a narrowed focus on one technique and a resultant misunderstanding around the wider risks associated with the applying force and managing restraints. The paper goes on to propose the 'transitional stabilizing position' (TSP) as an alternative concept and puts forward a dynamic risk assessment model. It explores how a shift in staff training away from developing pure competence in the performance of tightly specified techniques to managing the patient in TSPs could conceivably reduce the relatively low risk of death or serious injury associated with the application of restraint techniques to an even lower level.

An audit of the use of breakaway techniques in a large psychiatric hospital: a replication study

This paper describes an audit study of the effectiveness of breakaway training conducted in a specialist inpatient mental health hospital. Breakaway techniques comprise a set of physical skills to help separate or break away from an aggressor in a safe manner, but do not involve the use of restraint. Staff (n= 147) were assessed on their ability to break away from simulations of potentially life-threatening scenarios in a timely manner, and using the techniques taught in annual breakaway or refresher training. We found that only 14% (21/147) of participants correctly used the taught techniques to break away within 10 s. However, 80% of people were able to break away from the scenarios within 10 s but did not use the techniques taught to them. This audit reinforces questions about breakaway training raised in a previous study. It further demonstrates the need for a national curriculum for physical intervention training and development of the evidence base for the content of such training as a priority.

Physical assault by patients against physiotherapists working in mental health settings

OBJECTIVES

There is a lack of empirical research about physical assault by patients against physiotherapists who work in mental health settings. This study aimed to ascertain the lifetime prevalence and 12-month incidence of assault by patients against physiotherapists in UK mental health settings. This research will inform the development of pre- and post-registration training programmes for physiotherapists.

DESIGN

Postal questionnaire survey.

PARTICIPANTS

Members of the Chartered Society of Physiotherapists' special interest group for physiotherapists working in the field of psychiatry.

MAIN OUTCOME MEASURES

Self-reported experience of physical assault by patients. Secondary outcome was self-reported training received to manage violent and aggressive patients.

RESULTS

Questionnaires were returned by 116/178 (65%) special interest group members. Fifty-one percent (59/116) reported that they had been assaulted at work during their career, and 24% (28/116) had been assaulted by a patient in the previous 12 months. Physiotherapists in mental health settings appear to be at greater risk of assault by patients than other non-nursing clinicians.

CONCLUSIONS

Physiotherapists who work in mental health are at similar risk of physical assault by patients as their nursing colleagues, who are required by the UK Nursing and Midwifery Council to receive education and training in the prevention and management of aggression and violence in their pre-registration training. The authors recommend that appropriate training should be included in pre-registration programmes for physiotherapists.