Physically Restraining Psychiatric Patients: More Harm that Good?
Breathing in the room with the air of dignity is far better than to live in an environment where you are powerless. Physical restraint refers to “any manual method, or mechanical device attached or adjacent to a client’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body” (Carson, 2006). On 24thApril 1950, the very first time restraints were used on 1300 psychiatric patients, one out of every eight was confined in a strait jacket or other restraining device for checking the efficacy of restraint in these patients. The researchers concluded that “The use of mechanical restraints for the control of disturbed mental patients cannot be justified on psychiatric ground” (Dr. Bay, 1950).
In today’s world, too much emphasis is placed on becoming skillful in the use of restraint; much more emphasis should be placed on becoming skillful in development of caring, respectful and empathetic relationship with patient. I came up with this topic because of the case scenario which I have observed in my summer clinical, in which a patient was forcefully restrained as she was trying to pull out her naso-gastric tube. The patient had bipolar disease and was experiencing its manic stage at that time. The ultimate result of that physical restraint leads to a sudden aggressive behavior with seizures in the patient.
Restraints are providing more harmful effects rather than giving benefits. The use of physical restraints in psychiatric setting can result in destructive consequences as it imposes a very negative impact on the patient’s sense of well-being. I argue that, application of physical restraints in psychiatric patients should not be exercised because it results in disrespect of autonomy, violate the individual’s dignity and can lead to emotional distress.
Most people would agree that physical restraints in the psychiatric patient result in disrespect of their autonomy and coercive treatment that is a paternalistic approach toward the patient. As psychiatric illnesses are often misunderstood by family members, they do not have the mental capacity to make a decision regarding the use of physical restraints. Additionally, restraints are used as a source of threats or a manipulative agent which results in forceful treatment.
On the other hand, a patient’s ability to exercise autonomy may conflict with the health professional’s duty of beneficence. The health care professionals are obliged to provide safety, competence and quality of care to patient. As per right of mentally ill people, appropriate protection and safety should be given to patient during care.
According to Dr. Steven Mirin, medical director of the American Psychiatric Association: “The rule is clear that restraints may be used to protect the safety of the individual patient” (Charatan, 1999). As the psychiatric patients are at high risk to harm themselves and often not maintaining the compliance to medication so restraint may be result in a therapeutic approach. It is true that restraints are one of the ways to provide benefit in the form of safety and compliance to the patient. But according to Mohr, April 2009 “It is unilateral decision making by care givers that a patient is “out of control” and in need of external control made on behalf of patients and against their will, has the potential to become paternalistic.”
This coercive decision made by family results in losing of voice in patients and decreases their willpower and determination. It also seems that risk of injuries and falls are increasing during restraining. Dharmayan(2003)and Varcarolis, Carson, Shoemaker (2006) conclude that “it seems that serious injuries declined significantly when restrained order were discontinued” so rather providing safety to patient, restraint provide more harm and injuries, like falls due to immobilization, blisters, sores rather than providing safety to psychiatric patient.
Physical restraints violate the patient’s dignity and self-esteem, furthermore creating humiliation. Many patients have expressed feelings of imprisonment “I feel like a bird in a cage”, and restriction of their freedom of movement “I can’t even bring my two hands together.”(C Gastmans, K Milisen, 2006).
The use of restraint in psychiatric setting is more traumatic than a therapeutic Character as the word “psychiatric” also play as a stigma in their life which violates their dignity. Adding restraint can result in feelings of shame, loss of identity, dignity and self-respect. On the divergent, the safety and dignity of health care professionals became on high risk in psychiatric setting when restraint was not used.
Haller (1990), Blair (1991) and Brick house (1997) have found that “Patients with a history of assault, substance abuse, organic brain syndrome, schizophrenia and bipolar disorder, and Axis II (personality disorder) are most likely to assault employees”. Therefore restraint can be used for the safety of healthcare professionals and others. As per Maslow hierarchy model safety and security of an individual is a second important need.
I partially agree that using restraint in psychiatric setting can result in the safety of healthcare professionals and others but if it is allowed than restraint misuse can became a risk and hence it can be used in according to convenience of staff by giving the reason of their own safety. This attitude would lend to violation of their autonomy and self-esteem and can lead to violence on health care professionals. According to Morrison in 1994, “Violence in psychiatric settings appears to have more to do with antisocial power and control behavior of patients.”(Brickhouse, 1997).
Thus, restraints result in more violence and loss of dignity in patient. Elk and Ferchau in 2000 found that “Nursing staff have reported feelings of guilt and embarrassment when using physical restraints, as they realize that restraint devices can contribute to a loss of patient dignity” (Janelli, Stamps and Delles, 2006). Physical restraints should be used in a way that the safety and dignity of the patient is preserved and should not be used for convenience of staff. Mostly people agree that physical restraints can result in further emotional distresses and psychological disturbances in psychiatric patients. These restraints act as an emotionally traumatizing agent in psychiatric patients.
Recent studies actually suggest that restraints can serve as positive reinforcers for aggression (Kahng, Leak, Vu and Mishler, 2008; Mohr, 2009). On the contrary, physical restraints are necessary in some circumstances to accomplish appropriate interventions in psychiatric patients for better prognosis and to control the certain harmful behaviors of patient.
Varcarolis (2006) explained that “Seclusion and restraints reduces overwhelming environmental stimuli and protects a client from injuring self. Even if it is true that restraints are effective for controlling destructive behaviors in psychiatric patient but that control will be for the short term and by restraining them we are making their aggression and anxiety level worst which would be harmful in long term for patients. For example, for attaining the compliance of psychotic medication we will restraining the patient for controlling their aggressive behavior but after restraining the level of aggression will became high due to restraints rather than to be decrease.”
Psychiatric patients have responded to such action (restraint) with anger, fear, anxiety, depression and stress related syndromes (Meiner and Miceli, 2000 and Carson, 2006).
In conclusion, being a part of the health care team, we should give respect to mentally ill patients. Being mentally ill does not mean that they are devoid of their feelings and self-esteem, they are not a waste of society that they are treated as aliens. Being locked up or restrained breaches their dignity and affects their sense of well-being.
I believed that use of physical restraints in psychiatric setting does not enhance client care as it disrespects one’s autonomy, violates one’s dignity and can lead to emotional distress. Therefore, physical restraints should not be exercised in psychiatric patients. It is recommended that there should be more research on this topic in context of psychiatric setting and importance should be placed on the development of caring, respectful and empathic relationship with patient, rather than becoming skillful in use of restraints and if in case restraints are necessary to use then they should be working in maximizing the dignity, respect and sense of wellbeing. With that, there should be certain policy for physically restraint so that the use of restraint became minimal.
• Varcarolis, E. M; Carson, V. B and Shoemaker, N. C. (2006). Foundations of psychiatric health nursing: A clinical approach. Saunders: Elsevier.
• Google timeline. Retrieved fromhttp://www.google.com.pk/search?q=History +of+restraining+the+psychiatric+patient&hl=en&sa=X&tbo=p&tbs=tl:1,tll:1950/01,tlh:1950/06&ei=9VMVS778McuHkQXxm6GQBw&oi=timeline_histogram_main&ct=timeline-
• Charatan, F. (2000, July 10). US reconsiders use of seclusion and restraints in psychiatric patients.British Medical Journal, 319, p 7. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116238/pdf/77b.pdf.
• Mohr, W. K. (2009, in press). Restraints and the code of ethics: Anuneasyfit. Archives of Psychiatric Nursing, 0, Pp1-12.
• Gastmans, C. and Milisen. K. (2006). Use of physical restraint in nursing homes: clinical-ethical considerations. J Med Ethic,, 32,(3), 148-152.Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468/pdf/148.pdf
• Brickhouse, E. A. (1997, July 7). Designated agency safety and health official letter 00S-97- Violence in psychiatric setting. Retrieved from United State Department of Veterans Affairs: http://www1.va.gov/VASAFETY/page.cfm?pg=213.
• Janelli, L. M., Stamps, D., and Delles, L. (2006). Physical restraint use: a nursing perspective. Med Surg Nursing.Retrieved on 02 Dec, 2009 from FindArticles.com. http://findarticles.com/p/articles/mi_m0FSS/is_3_15/ai_n17213666/.
• Paterson, B., and Duxbury, J. (2007). Restraint and the question of validity. Nursing Ethics, 14 (4), 534-543.
About the Author: Maryam Lakhdir is currently working at AKUH as bone marrow transplant nurse and is dealing with certian group of oncology and hematology conditions. I have done my bachelors in nursing from AKUSON, Pakistan and now pursuing Masters in Epidemiology and Bio-statistics. She can be reached at firstname.lastname@example.org
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