Relying on Restraints in Psychiatric Settings: Distasteful yet Necessary?
In a medical context, restraint is defined as “forcible confinement or control of a subject, as of a confused, disoriented, psychotic, or irrational person”. Counsel and Care UK, (2002) calls it the “intentional restriction of a person’s voluntary movement or behavior”.
In psychiatric settings, both physical and chemical methods of restraint are in current practice. Physical restraint is the use of any device, material or equipment attached to or near a person’s body, which cannot be controlled or easily removed by the person, and which is deliberately intended to prevent a person’s free movement and/or normal access to their body (Gastmans and Milisen, 2006).Meanwhile, chemical restraint is any medication given primarily to control a person’s behavior, rather than to treat a mental illness or physical condition (Chief Forensic Psychiatrist Clinical Guidelines 10, 2013, p. 2).
During my clinical rotation in psychiatric ward I encountered a patient with persecutory delusion and auditory hallucinations. It was his belief that the CIA was trying to arrest him, and that everybody around him was accomplice in it. He would go to his room again and again, thinking that somebody had been calling him persistently. He displayed aggressive behavior and tried to harm others. Finally, he was restrained by the staff for an hour. During this while, he was still angry and agitation and eventually tried to harm himself and got a bruise on his forehead.
Coming across this scenario, I chose to highlight this topic: the purpose, use and impact of restraint. According to a study conducted by Aga Khan University, out of 57 patients requiring physical restrain, 69% were males while 31% were females. 64% patients were less than 35 years of age. The most common condition among these patients was schizophrenia (31%), followed by bipolar disorder (30%). Violent, threatening and agitated behavior was the most common reason for being placed under physical restraint (Iqbal, Naqvi, & Siddiqui, 2006, p. 35).
Admittedly, the use of restraints is controversial; an ethical grey-zone.
Taking into account the socio-cultural aspect of restraint, it is necessary to incorporate ethical framework of Autonomy vs. Beneficence vs. Justice. Autonomy is about respecting every individual’s rights and allowing one to take their own decisions. In case of patients with mental illness, restraint should be reduced to a last option. Although controlling a client overrules their freedom, it supports the patient’s right to remain safe from physical harm.
Restraint is only acceptable in cases where a client provides voluntary consent; is at greater risk of harming self or others; or for self-defense of a nurse where a client is extremely violent (Royal College of Nursing, 2008). The argument of ‘beneficence’ is used to justify disregarding the patient’s autonomy. It is an ethics principle to take positive action to help a client.
According to Swiss Academy of Medical Sciences, coercive measures in response to a risk to the patient are acceptable only if the patient is incompetent. It is further necessary to strictly limit the duration of restraint. When the emergency situation resulting in the application of restraint ceases to exist, the patient should be released immediately (Petrini, 2013).
Moving on to the causes, there could be many reasons why patients are restrained. These include “protecting patients from injury, maintaining treatment and controlling disruptive behavior” (College of nurses of Ontario, 2009). In case of my client the purpose of restraint was to control his aggressive behavior and protect others from his aggressive behaviour. All around the world, threats and violence perpetrated by patients in psychiatric emergency inpatient units are quite common and are prevalent factors concerning the application of mechanical restraints” (Lanthén, Rask, and Sunnqvist, 2015).
The use of restraint is argued to achieve therapeutic effects. These effects include control of anger, aggression, and harm to others and most importantly self-harm. According to (Sequeira and Halstead, 2002) “female patients have expressed feelings of comfort or safety associated with restraint when female staff members restrain them, to the extent that they deliberately behave in ways which provoked its use” (Stewart, 2009). Contrary to this, using restraint damages the trusting relationship between patient and staff. “When you restrain a patient, well the patient blames the nurse and becomes skeptical towards him/her” (Moghadam, Khoshknab and Pazargadi, 2013).
Further, there are certain traumatic events associated with this act “some of the damaging effects of restraint are feeling abused, worthless, helpless and demeaned. Restraint may also trigger post-traumatic stress symptoms” (Knowles, 2015). Flashbacks and reawakening of previous negative events were also stated by few patients (Bonner, 2007). Certain risks are associated with improper handling and may cause some life threatening conditions; “Placing a restrained patient in a supine position could increase aspiration risk, placing a restrained patient in a prone position could increase suffocation risk, using an above-the-neck vest that’s not secured properly may increase strangulation risk” (Springer, 2015). Fractures and ulcers are most frequently reported injuries as well (Berzlanovich, Schöpfer, and Keil, 2012).
In order to tackle this dilemma of restraint in the best way, measures should be taken at various levels. From an individual perspective, one should provide most support to the patient. As a nurse, keeping the ethical framework in mind is essential. Along with keeping an eye on patient’s condition that includes monitoring vital signs, assessing patient conditions such as skin integrity, colour, circulation etc is a prime duty. It is very important to choose the appropriate type of restraint according to patients’ physical condition.
Patients who are restrained usually suffer emotional disturbances; hence a nurse should be ready to provide support and reassurance. Further, to keep a trusting relation between client and patient intact, debriefing is necessary. “It is a desire expressed by the patients to talk about their experience in the mechanical restraints situation. The possibility of debriefing with staff was seen as a way to process the experience” (Lanthén, Rask and Sunnqvist, 2015).
According to Whakaaro Nui (2014), this practice involves a review of events leading up to restraint incident and the identification of staff and client’s actions that would help avoid further coercion. The literature suggests that there are three key components to patient’s debriefing; behavioral analysis, education and collaborative problem solving/planning (pp. 5).
On national and international levels, global policies should be formulated and implemented in all health care settings. The indications and general principles for restraint should be kept in mind. In addition, all health care workers and staff should be trained how to appropriately restrain in order to minimize injuries (Tziggili, Stewart, Bowers, Simpson & Ryan, 2009).
In conclusion, restraint is an ethical issue that, in a cultural perspective is taken as exploiting ones rights. However, in a psychiatric setting it is an essential strategy to control and prevent a patient from causing harm. Although studies have shown its negative impacts on patients but it is always used as a therapeutic way and a last room for treatment.
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Whakaaro Nui, T. (2014). Debriefing following seclusion and restraint A summary of relevant literature. The National Centre Of Mental Health Research, Information And Workforce Development., 5. Retrieved from http://www.tepou.co.nz/uploads/files/resource-assets/debriefing-following-seclusion-and-restraint-281014.pdf
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