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Physical restraint in a therapeutic setting; a necessary evil?
International Journal of Law and Psychiatry 35 (2012) 43–49
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International Journal of Law and Psychiatry
Physical restraint in a therapeutic setting; a necessary evil? Elizabeth Perkins a,⁎, Helen Prosser b, David Riley c, Richard Whittington a a b c
Health & Community Care Research Unit, University of Liverpool, UK Centre for Social Justice Research, University of Salford, UK Mersey Care NHS Trust, Liverpool, UK
a r t i c l e
i n f o
Available online 16 December 2011 Keywords: Physical intervention Restraint Coercion
a b s t r a c t Physical restraint of people experiencing mental health problems is a coercive and traumatic procedure which is only legally permitted if it is proportionate to the risk presented. This study sought to examine the decision-making processes used by mental health staff involved in a series of restraint episodes in an acute care setting. Thirty nurses were interviewed either individually or in focus groups to elicit their views on restraint and experience in specific incidents. Four factors which influenced the decision to restrain were identified: contextual demands; lack of alternatives; the escalatory effects of restraint itself; and perceptions of risk. While some of these factors are amenable to change through improvements in practice, training and organisational culture, nurses viewed restraint as a necessary evil, justified on the basis of the unpredictable nature of mental illness and the environment in which they worked. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction Physical restraint of people experiencing mental health problems against their will is an intrusive and risky procedure which is only legally permitted in very specific circumstances. In most jurisdictions, these circumstances include detention under the relevant mental health legislation. Such detention does not, however, eradicate the requirement for the intervention to be proportionate to any risk perceived by the practitioners (NIMHE, 2004). There is an expectation that ‘best practice’ means practitioners will strive to de-escalate behaviour and so avoid restraint whilst maintaining a safe environment. If staff have to use restraint it is expected that they will use the least intrusive method of restraint appropriate in the circumstances. Since physical restraint can range from firmly holding the person's arms whilst they remain standing to forcing the person to the floor and pinning all four limbs down (‘takedown’), there is always a choice to be made about the degree of force even once the decision to implement restraint has been taken. Notwithstanding the drive to establish consistent standards of good practice in this area, such judgements of proportionality and decisions on when to implement physical restraint are highly complex and inevitably somewhat
⁎ Corresponding author at: Health & Community Care Research Unit (HaCCRU), Institute of Psychology, Health and Society, University of Liverpool, Liverpool L69 3GB, UK. Tel.: + 44 151 794 5909(direct line), + 44 151 794 5503(office); fax: + 44 151 794 5434. E-mail address: [email protected] (E. Perkins). 0160-2527/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijlp.2011.11.008
subjective. They have been subject to legal challenge in the UK and elsewhere (e.g. R on the Application of AC –v- Secretary of State for Justice). Coercive physical interventions (PI) such as restraint have been a controversial aspect of psychiatric care since the time of Pinel with a consensus which lasted into the 1990s that such interventions are an inevitable, albeit undesirable, means of ensuring safety. The potential traumatic effects of PI use are well-established (Chien, Chan, Lam, & Kam, 2005; Cusack, Frueh, Hiers, Suffoletta-Maierle, & Bennett, 2003; Frueh et al., 2005; Hoekstra, Lendemeijer, & Jansen, 2004; Lancaster, Whittington, Lane, Riley, & Meehan, 2008; Meehan, Bergen, & Fjeldsoe, 2004; Paterson, Bradley, & Stark, 2003; Robins, Sauvageot, Cusack, Suffoletta-Maierle, & Frueh, 2005; Wynn, 2004). However, it is only recently that a groundswell of opinion has developed in North America, Europe and Australasia over the past decade against the use of PI as a part of everyday mental health care (Huckshorn, 2004). PI, in this new ‘zero tolerance’ thinking, is either always illegitimate by definition, or should be restricted to a very small number of highly risky situations. In the context of a mental health system which espouses core values of collaboration and partnership with service users, PI is viewed as a professional and systems failure requiring intensive scrutiny and executive action. Such a culture shift increases the pressure on practitioners to reflect on their practice in terms of the proportionality of response to the perceived risk. In particular, in relation to this study, the choice between standing (‘vertical’) restraint and ‘takedown’ to the floor (‘horizontal restraint’) is pertinent and worthy of examination. The study on which this paper is based used a recent physical restraint episode as a basis for exploring the attitudes of staff towards
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restraint and as a way of beginning to unpick some of the influences on their decision making and behaviour.
described the attempted balancing and weighing of risks when talking about one new service user who had been making threats of physical assault.
2. Methods Thirty nursing staff working in an acute adult mental health setting in the UK were recruited to the study; of whom, fifteen were interviewed individually, thirteen took part in focus group interviews and a further 2 took part in both. The individual interviews were undertaken in 2007 within two weeks of a restraint episode occurring. They involved a range of nursing staff that included staff nurses and ward managers, on both day and night shifts. The individual interviewees included 9 women and 8 men, who ranged in age from 25 to 56. All respondents had worked in an acute mental health inpatient setting for between 18 months and 25 years. The interview was designed to explore the restraint incident retrospectively, using it also as a basis for discussion of more general views and attitudes on the use of restraint. Both individual interviews and focus group discussions were conducted in a private and confidential location within the mental health trust. All interviews and focus groups were audio-recorded and transcribed verbatim after first gaining the written consent of participants. All quotes have been anonymised or attributed to a pseudonym. Interview and focus group transcripts were read and re-read to identify the main thematic areas. Since the aim of the study was to uncover new insights into the factors influencing restraint, the emphasis was on identifying variation in accounts, rather than in quantifying the frequency of particular types of experience. Analysis began by organising the data into broad domains based on the interview and topic guides. Consistent with a thematic analytic approach (Charmaz, 2006), further themes, categories and subcategories were constructed from the data as analysis proceeded. Categories and themes were explored for consistency and compared within and between transcripts in order to examine variations in responses. Finally, key concepts were identified by re-reading the categorised data and searching for links between each concept. This process also incorporated a search for any anomalous findings, with conceptualisation revised to take account of these. The study was approved by an NHS Research Ethics Committee. 3. Findings In the majority of restraint incidents discussed with staff, the service user was moved to the floor and restrained in a horizontal position. In only 2 incidents the service user was restrained in a vertical (standing) position and in one of these the staff member interviewed stated that a move to the floor would have been preferable had space permitted. Staff identified aggression or violence, self-harm, absconding and the planned administration of medication as the antecedents leading to restraint. There were a number of factors that staff identified which help to explain why restraint is seen as an important intervention within mental health institutions. These will be explored in more detail starting with the contextual demands, moving on to the sense of a restricted range of available options, the escalatory effects of restraint itself and finally perceptions of risk. 3.1. Contextual demands A recurring perception throughout the interviews was that organisational demands and ward factors created the climate in which difficult behaviour developed and escalated. There was recognition that changes in the service user population impacted on the dynamics on the ward. Not just between staff and service users but also between service users. Staff were more cautious in their dealings with individuals who they did not know very well. One staff member succinctly
He has got no history of aggression … but I think his bark is worse than his bite, but I don't know, I have never nursed him before, so I don't know how much he would escalate and when he would back off, if he would, so I don't know, he is a bit of an unknown quantity really. (Interview 17) The sense of knowing an individual, or having built up a relationship with someone and recognizing their behavioural pattern and triggers helped inform staff's expectations of an individual's behaviour and, in particular, the risks posed. If you know a person's potential, and you know what their strengths and weaknesses are and whether you can actually talk somebody round then it's always easier. With somebody who is an unknown, who has a previous recent history of aggression towards family and friends, then you know that this person is more capable and more likely to lash out and hurt somebody, than somebody who has no previous contact, but hasn't got a history. (Interview 6) The use of past behaviour as a predictor of future behaviour provided staff with a frame of reference which in certain circumstances increased the likelihood of de-escalation and decreased the use of restraint. I didn't feel that unsafe because I knew there were two staff with me, because I had got quite a good relationship with him… I didn't feel that threatened. (Interview 16) So if they trust you and you know them, it makes a difference …but if you know someone, you can often spot the triggers, the warning signs, you know the triggers, you know when they're building up to it. (Interview 9) While staff reported that knowing an individual provided a basis for a good relationship and therefore for de-escalation, they felt that staffing levels prohibited the amount of time they had to spend with any one individual. So, while de-escalation was seen as important, staff felt that it was not always possible within the context of their current staffing levels to develop the relationships which made it possible. You would have to spend an awful lot of time talking with them, which is probably time that… while you are spending so much time trying to de-escalate you are actually taking your time away from other patients who probably need your help more than the actual other person. (Interview 10) Ironically, while recognising that preventing a situation from escalating took time, it was also recognised that restraint episodes were also labour intensive, often requiring higher staffing levels and drawing staff from other wards. We had three incidents last night, one was a restraint, one was diffused and one a meds issue, but there was only four staff on the ward so we had to use six additional staff from other wards, which of course leaves them short. (Interview 8) Interestingly, although staff were familiar with de-escalation strategies which focused on neutralising behaviour, (e.g. reducing external stimuli; removing other service users from the area; moving the service user to a safer, or more quiet and private environment; calming the service user by showing signs of listening and acknowledgement of their concerns), in everyday use de-escalation focused
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on communicating with the service user and often directing the service user to modify and contain their behaviour. Paradoxically, communicative de-escalation techniques were deemed to be of least value where a service user was suffering from acute and uncontrollable psychiatric symptomatology. Usually we try and de-escalate it by talking to the patient… but sometimes because they are so unwell, and at the time it could be through hearing voices, or through their illness, could be alcohol or drug abuse, then no amount of talking can actually stop the patient or the service user. (Interview 3) In the context of a changing service user population and what staff perceived to be low staffing levels, it was not surprising that two respondents reported the inconsistent management of service user behaviour as a contributory factor to behaviours leading to restraint. These staff felt that a more objective and consistent approach should be adopted in defining the behaviours to be tolerated, and the steps that should be taken to intervene earlier in managing disruptive and agitated behaviours: I think though that some situations could be avoided, or the potential for situations could be avoided. It's important that the clients know what the boundaries are and that these boundaries should apply to everyone, everyone has to be treated the same. … If some clients are treated differently then that creates tension between staff and clients and it can lead to resentment, frustrations, so behaviours can get difficult. (Interview 8) There was also the sense that the threat of restraint was occasionally used as an alternative to de-escalation but with a view to deterring or modifying behaviour. Again, it was recognised that this in itself might be seen as provocative and have the opposite effect from that intended. I have heard members of staff say, “well don't do that, if you do that, the consequence will be….”, well that, that's provocative to me, that is provocative, that is going to anger a person. (Interview 1) Restraint is used as a means of controlling a difficult patient in difficult circumstances. I think sometimes, and this is just my perception, that sometimes, in reality, it is used as a threat rather than a means of… it's used proactively, rather than reactively I think, that's the best way I can put it. (Interview 14)
3.2. Lack of alternatives While the majority of staff acknowledged the existence of a progressive approach to restraining an individual; with horizontal restraint being the last resort, the reality was that the majority of incidents resulted in horizontal restraint without any intervening positions being tried. In only a small number of incidents was vertical restraint reported to have been used as an initial procedure in a progressive step-wise process. If staff felt that they could control the service user's behaviour and the service user was calming down and becoming compliant with staff directions, then a move to horizontal restraint was seen as unnecessary. In the majority of incidents the service user was reported as either physically assaulting or attempting to assault others physically, or was threatening physical violence against others. If the service user resisted attempts to be restrained and staff felt they were unable to reduce the targeted behaviour in vertical or sitting restraint, then restraint was reinforced by moving the service user to the floor. Well, I know in the C&R (training) you are encouraged not to bring the person down to the floor right away as a matter of course, if you feel
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you don't have to, you can restrain somebody on their feet, or even just sort of half way which is on their knees, most restraints are still brought down to the floor. (Interview 1). Initially he was standing up, as I say we had his arms, trying to get his arms down his side, just to stop him from lashing out and hitting us, that was proving unsuccessful because of his fitness and the excitement of the patient himself, he was quite threatened by this and I think that made him a lot more hostile to us initially. And it finished up we just had to pull him on the floor just to make sure that his legs weren't a problem because of his height. (Interview 6) Acts of actual violent assault or the threat of assault were usually reported to be involved where staff proceeded immediately to horizontal restraint. He was punching me in the head mostly and then he was kicking me as well in the ribs, in the side, my chest and that, and then I fell backwards to the floor, and as I fell backwards to the floor he was …, still punching me and kicking me while I was down on the floor, and I managed, he stumbled a bit, and as he stumbled I just managed to jump up, and while I was waiting for the rest of the staff to come to my assistance, I had to get his head in a head lock and like pull him half way down to the floor and then the rest of the staff responded and he had to be restrained then. (Interview 12) When describing incidents involving a rapid move to the floor, respondents' accounts often suggested that explicit decision-making was overtaken by an instinctive or intuitive response. He just ran right at me and he was, I was sort of like by the door standing up, with my back against the wall, he just ran at me, sort of like with his head down and his arms out, to go to punch me. So instinct really I just protected myself and as he got closer, I grabbed his head and brought his head down, because the lower you bring a person, the more difficult it is for them to punch you. (Interview 4) The notion of protecting the self and others from physical harm or intent was used by the staff as justification for using horizontal restraint. However, it also became clear that within staff accounts there was a sense in which particular triggers elicited standardized responses. For instance, as described above and below, physical assault was likely to trigger a decision to use horizontal restraint in self-defence. I mean personally I don't think any of that training, the C&R, equips you for it, does it? It just helps you after you have got them on the floor to keep them down in a safe way. But before that it's just, that is just, it's them or you isn't it. (Interview 13) The overriding concern when faced with violence and aggression or a perceived intent to harm, was the need to act quickly. This sense of urgency often seemed to result in an unsystematic restraint episode, rather than a graduated, progressive sequence. Describe the way we did it? Well really on restraining and taking someone down, we wouldn't know how it happens because it happens that quick, that you just, it's just a scrap to be quite honest. It is a scrap. I mean you get taught all these methods …It doesn't work. To be quite honest, it's dog eat dog. (Interview 13) There's no training that can ever really portray what it's like to go hands on, and I think the course is really good, but when you actually, when you're in a situation when you're about to restrain someone very seriously, … everyone's adrenalin is going and everyone can just sort of jump in really without there being that control. (Interview 15)
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In these circumstances, the ability to make clear decisions about restraint was over ridden in the eyes of the staff by the need to control the service user's behaviour. We had to use restraint, there was no other option of controlling him. (Interview 12) Throughout the interviews, staff, while recognising the notion of restraint as a means of last resort, viewed it as a ‘necessary evil’, that is a necessary strategy in controlling behaviour and reducing the risk of violence and harm even though the majority of staff talked with dislike about its application. You need it because it's for your safety and other people's safety. Because, you just need it there because if you didn't have it, people could get hurt. I mean I know it's not the nicest thing, and it is uncomfortable, but you have got to look at it, at the safety aspects of what could happen if we don't use restraints. (Interview 2) For the majority of the respondents there was a clear association between mental illness and the service user's inability to control their own behaviour which created the context in which the need for restraint was almost normalised. I just think because of the type of people you are dealing with … I think it's a natural progression, that some people will become aggressive because of their state of mind. (Interview 17) It's driven by mental illness, and basically they are not so much aware of what they are doing, they are not really responsible for what they are doing, and because of their mental illness I think you don't know how far they would go, so they are really dangerous, … some patients you will get, and they are that mentally ill, that psychotic they are constantly hearing voices, telling them to harm people, and so they are the ones who are really unpredictable who I think could, you know, go as far as killing people. (Interview 17) But I think it happens too often as well on our ward anyway lately....we restrain on a daily basis sometimes. (Focus group3; P1) The nursing staff in this study judged that all of the incidents of restraint discussed in the interview had been used appropriately, and, on reflection, considered that little could have been done differently to prevent the incident from occurring. Very few staff reported feelings of disquiet over their own practice in handling the incident after it had finished or after their shift had ended. There was only one respondent who reported that the process itself could have been executed better, but none felt that restraint had been used inappropriately. References to ‘taking control’ formed a central feature in staff's rationalisations of the use of horizontal restraint. This related to one of two conceptualizations: a) restraint as a technique to directly suppress aggressive and violent behaviour; and b) restraint as a management strategy to maintain order and stability within the organisational setting. We had to move her onto the floor because we just couldn't control her on the bed, we were all moving, so the only way we could control her, she was lying face down and there was one on either arm, one on the head, and two on the legs because she was strong, and we had to talk her round for about 45 minutes, she was on the floor. (Interview 2) Actually I have never used the vertical restraint. … you have more control when you take people down to the floor. (Interview 4)
As the above examples demonstrate, horizontal restraint is considered the most expedient and effective means in disempowering the service user and rapidly subduing the targeted behaviour. At the same time, staff rationalised the use of restraint in terms of acting to minimise harm and keep individuals safe. Significantly, however, staff emphasised that whether an individual was restrained horizontally or vertically, or on their front or back was rarely a matter of choice. More often it resulted from a lack of other options. Two situational factors influencing restraint position were cited: space and immediacy. Limitations of physical space and the physical positioning of the service user contributed to the restraint position used. The second dimension to taking control concerned threats to the established order and stability of the ward. The importance of maintaining control over service user's behaviour on the ward was evident in a number of accounts. Threats to the functioning and stability of the ward were important factors in deciding to use restraint, not least because it was recognised by staff that the intensification of agitated and disturbed behaviour could spread across individuals. I mean when you are working on a ward like this, I am always well aware that shouting, screaming, commotions on a ward affects all the other patients on the ward and there is a lot of people here with like anxiety problems and things, so I felt I needed … to calm the situation down. (Interview 17) While the overall safety of the ward environment may be at the heart of such rationalisations, there is an evident tension between maintaining the therapeutic environment and the best interests of the individual service user. 3.3. The escalatory effects of restraint Once restraint is implemented it seems that the end goal is simply an attempt to reduce the undesirable behaviour (crisis intervention), with the specific causes or antecedents to it becoming inconsequential in the effort to take control. However, all staff reported that the physical intervention itself becomes the battleground for control between staff and the service user with each seeking to gain the upper hand. The minute you lay hands on, the incident that originally got you to that point, is lost, it then becomes a situation of well you know, get off me, I will calm down when you get off me, and then the retort from the staff side is well no, when you have calmed down, and the service user then says well I will calm down when you get off me, and it then becomes a stalemate … a service-user, might calm down quicker if the restraint wasn't so long, instead of being forced, as it were, into submission, sort of like we will take hands-off when we feel you have calmed down. (Interview 1) Indeed, while staff reported making efforts to explain the purpose of the restraint to the service user, at the same time, they were highly directive and demanding of the service user. Staff generally considered control of the situation to have been established when the service user exhibited signs of submission and co-operation. She looked at me, she said ‘I fucking hate you, I really hate you’, and the venom in her face was like unbelievable and that's when we kept her down. You know for a fact when they have calmed down. (Interview 13) You know every time you loosen your hold or take any pressure away, if he is trying to get up and fight you then you say, ‘no, just lie still, we don't like to do this anymore than you do, erm, just relax.’ (Interview 6) Respondents acknowledged that service users were not routinely given the opportunity to discuss their experiences following an
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incident of restraint or given a clear explanation of the decision to use restraint. Staff reported that this was generally left to the discretion of staff and was dependent upon an assessment of the service user's mental state and capacity to comprehend.
a point where you feel that any second now instead of being stood against the wall and lashing out with a distance between you, he is going to come at us, and at that point we said like, and that is when we actually put hands on. (Interview 6)
I have never really asked them, I have never actually gone back and said, ‘well ok how do you feel about it?’ Perhaps we should do. (Interview 10)
Although staff report that they assess escalating situations within the context of safety to self and others, not all escalating situations were deemed to be dangerous. Another further element that appears to have an influence on decision-making is individual staff's tolerance of risk and uncertainty. Several respondents recognised that restraint was sometimes used too quickly.
Interestingly the staff also reported the need for debriefing and support following restraint incidents. When a restraint happens…, we don't talk about the restraint, we don't talk about what happens, what we done well, we don't learn about the restraint, we just sort of fuddle on, back onto our jobs, and do what we do again and then a restraint comes again and we do the same thing, we don't learn. (Focus group 1; P 4)
3.4. Perceptions of risk In trying to understand the way in which restraint was used in this secure forensic setting, perceptions of risk emerged as a crucial driver. Risk was regarded as a part of everyday mental health care for the members of staff involved in this study. How risk is played out in this setting is complex. While staff adopted a discourse of risk assessment and progressive de-escalation in their interviews, they also described how perceptions of risky behaviour in practice often triggered a reflex restraint response. Perceptions of risk, however, appear to be formed quickly and intuitively based on responses to actual or attempted physical violence and were also linked to particular situational contexts. One staff member described how a judgement about the use of horizontal restraint was made instinctively after being assaulted in the face. It was almost a reflex action in the sense that you make all these judgements very quickly and the safest thing to do seemed to be to take him straight onto the floor. (Interview 14) When you hear that noise you just drop everything and go and you have got to, because it could be your colleagues in danger, it could be a client in danger, you just, you have got that instinct to just go and see what it is. (Interview 2) Behaviours that are regarded as having high probability of causing significant and immediate harm are instinctively constituted as exposing staff to high risk. This was also clearly the case for behaviours that were seen to erupt without any warning signs. As noted previously, horizontal restraint is seen as a situational necessity in order to minimise the risk of harm and to exert control. If … you were planning that you were going to have to go and restrain someone because, I don't know, they were smashing up the dining room or something, then in those circumstances you would be planning to go in as a team to take them straight to the floor, …because if they were already actually being aggressive and violent, you probably wouldn't take the risk of standing and it demobilises them quicker. (Interview 16) As the above quote suggests, the challenges for staff arise from assessing the risk in various situations, and predicting the outcome and consequences of a situation. An assessment of the concurrent level of threat, the attribution of intent and the interpretation of a given behaviour are critical mediators in making this calculation. I was asking him would he come sit with the Dr, he wasn't having any of it, as I say he started spitting at us and lashing out. And there comes
Sometimes some people go in too hastily I think, instead of just standing back and talking, you know de-escalate, a lot of people think a patient raises their voice, and their arm comes up and get on top of them and I don't think there is any need for that. I mean, sometimes there is a need for it, but I don't think there is a need for it half the time. (Interview 10) Differing degrees of risk tolerance may help explain the variation in restraint procedure that some respondents acknowledged between individuals. Staff surmised that those who they saw as intervening ‘too hastily’, were perhaps fearful and thus overly-cautious, in responding to risk. I mean you know it might be fear of getting smacked, let's just get it over with now and cut down the possibility of getting smacked. (Interview 10) Some staff I feel because of lack of confidence will go in sooner rather than later, because they don't want the situation to escalate, rather than give it time to de-escalate. They would say they are being more pro-active because they feel that the risk was there, that's their assessment. (Interview 6) Clearly, the staff interviewed recognised different perceptions of risk and danger and perhaps more importantly read situations in different ways. There was uncertainty about reliably predicting how events would unfold leading some staff into a physical intervention almost as a pre-emptive strike. Of course this risked creating the situation that staff were keen to prevent — a physical struggle. I don't think you can take the chance to think well maybe they won't strike out again. I don't think you can wait to be hit. I think you just automatically…when someone is actually aggressive towards you, putting hands on keeps everyone safe. (Interview 17) Keeping everyone safe was very much informed by knowledge of a person's behavioural or restraint history. There was little acknowledgement, however, that this view could perpetuate the use of physical intervention as a first line strategy for particular service users who appeared to have a history of violence and aggression. The previous night he'd actually attacked another member of staff and punched him three times in the head, so I was already on alert… We had to take him down to the floor. (Interview 8) As already reported above, there was a common perception that there were clear differences between staff in the way they approached restraint. Personal qualities and individual tolerance levels of aggression and violence were forwarded as explanations of this difference. There are some people who always seem to be involved in C&R and I wonder why that is. The same staff, the names keep cropping up in C&R incidents and I wonder if they're too quick to go hands on rather
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than to continue to try de-escalation and to try other tactics. (Interview 15) There are different staff attitudes and some staff can be aggressive, which doesn't help the situation. If you're highly charged and you've got a member of staff who comes in bluntly, saying ‘calm down’, it can have the opposite effect. Some staff are better at dealing with patients than others, it's their attitude, some people just know how to calm people down better than others. (Interview 9)
4. Discussion The research literature on the use of restraint is quite extensive now but given the difficulties of researching emergency situations is bedevilled by methodological limitations. Although Exworthy, Mohan, Hindley, and Basson (2001) report a role for restraint in the prevention and reduction of disturbed behaviour in a therapeutic setting, a Cochrane Review (Sailas & Fenton, 2000) found no controlled studies that evaluated the effect of restraint or seclusion on those with serious mental illness. Notwithstanding this there appears to be a consensus that the use of physical restraint in psychiatric settings is pervasive. In a recent survey of 307 PICUs and Low secure units in the UK Pereira, Dawson, and Sarsam (2006) reported that the majority used control and restraint as core interventions to manage disturbed behaviour. There is also extensive national guidance in the UK based on the assumption that restraint is an unfortunate but inevitable part of mental health care. This study explored how restraint is viewed and used by staff working in an acute mental health setting. Successful de-escalation and the less intrusive forms of restraint, such as holding the person whilst standing, were less evident in the interviews but had they been present, might have given insight into the successful use of minimal force. Given the small scale nature of this study and its focus on staff in one institution it is perhaps not surprising that there was little discernible difference in the views of staff taking into account their age, gender and clinical experience. Four groups of factors were identified by staff to have influenced the use of restraint; contextual demands; lack of alternatives; the escalatory effect of restraint itself; and; perceptions of risk. The study highlights the complex and sometimes contradictory interaction of variables which were perceived by staff to influence their decision to use restraint. At the same time as talking about the importance of building relationships and trust between staff and service users, staff talked about policy changes which brought new and demanding service users onto the wards leaving them little time to develop relationships and mutual trust. Staff identified a range of techniques for de-escalation but almost exclusively relied upon communicative strategies which they recognised as likely to be the least effective strategy given the service user's mental state. They talked about maximising time with the service user to get to know him/her before crises developed but recognised that the resource-intensive nature of restraint drew staff away from interacting with other service users not involved in the restraint episode. In addition, staff recognised the inconsistencies which existed in the use of restraint with staff holding different thresholds for intervention depending on their perception of the risk posed at the time. They reported situations in which formal risk assessments are overridden by intuition and the need to manage a crisis raising perceptions of personal threat and in so doing triggering restraint. Importantly, staff identified the inherent tensions that exist in acute mental health care provision today as a justification for the continued need for restraint as an intervention. Not surprisingly therefore, whether used as a threat to prevent escalation or as an actual intervention to manage a situation, restraint was viewed as a necessary evil. Other studies also report that nurses see restraint as a necessary part of their job but one that they would like to minimise (Bigwood &
Crowe, 2008). A postal questionnaire survey of 269 nurses in regional secure and psychiatric intensive care units in England and Wales which examined nurses' last experience of using control and restraint (Lee et al., 2003) reported that most nurses (96%) reported positive outcomes of the restraint. However a quarter of respondents also expressed concern about the impact on patients and some found the experience of restraint demeaning and stressful. It is possible that restraint may provide staff with a strategy for resolving the risk ambiguities inherent in working with potentially violent and aggressive individuals. In this study staff reported violence and aggression as major precursors to a restraint episode. This association between the use of restraint and patient violence is reflected in much of the psychiatric literature. However, a study of post-incident manual restraint forms analysed by Ryan and Bowers (2006) found that violence was rarely mentioned as a cause for restraint. The most common reasons related to more general disruptive and challenging behaviours. Stewart, Bowers, Simpson, and Tziggili (2009) suggest that there is a distinction between the causes entered on incident forms and the factors which determine the management of an incident. Whilst this is a possible explanation of the difference it does raise questions about the factors which influence the way in which restraint episodes get recorded and why disruptive and challenging behaviours result in restraint. The most recent National Audit of Violence within Working Age Adult (Psychiatric) Services (Healthcare Commission, 2008) reported an increase in the nature, level and severity of violence on wards. The authors also stated that the ‘effectiveness with which staff teams prevent and manage incidents has also increased’, with ‘clear evidence that the majority of services are now adopting proactive and preventive strategies to tackle violence in inpatient services’. The staff interviewed in this study had been trained to use Physical Intervention and saw it as a way of preventing individuals from “harming themselves, endangering others or seriously compromising the therapeutic environment” (National Institute for Health & Clinical Excellence, 2005:9). What is not clear from the study is how and indeed whether, this training had an impact on the proportionality of the restraint imposed in relation to its antecedents and on the frequency with which staff use this form of intervention. Given the complex nature of the use of restraint it cannot be assumed that improved training on its own will reduce the incidence of restraint. Health services in the United States have been actively working on reducing and preventing restraint, driven, according to LeBel (2011), by a number of largely unreported deaths arising from both restraint and seclusion. Widespread adoption of the Six Core Strategies model appears to offer the opportunity for a more holistic organisational alternative to the reliance on coercive interventions than does the implementation alone of training programmes for individual members of staff and care teams. The six elements are; (i) leadership towards organisational change (ii) using data to inform practice (iii) workforce development (iv) use of seclusion/restraint prevention tools (v) consumer roles in inpatient settings and (vi) debriefing. Nine years after the first implementation of the Six Core Strategies model, LeBel, Huckshorn, and Caldwell (2010) have reported a number of success stories. Not only has the number of restraint/seclusion episodes decreased in a number of services in which it has been implemented but also a range of other benefits have been reported. Most notably these include a reduction in staff turnover, staff injuries, absenteeism and retraining costs (LeBel, 2011). These six elements appear to offer staff and patients support in creating and sustaining a therapeutic environment on an ongoing basis. It does however require substantial commitment from all levels of the organisation based on a recognition from the top down of the systemic nature of the problems which underpin the frequency with which restraint is used. Contrary to the rhetoric of partnership working in which service users are active participants in their own treatment and nurses have
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a clear therapeutic role, the nurses in this study expressed a resigned acceptance of the conditions and limited options which they felt gave rise to the need for physical intervention. This may reflect broader problems in terms of the purpose and success of both acute in-patient services in general (Warner, 2005) and mental health nursing in particular. Numerous reports have identified the therapeutic poverty of many acute wards and the attendant problems of boredom and frustration (Care Quality Commission, 2009; Department of Health, 2002). Hopton and Glenister (1996) reported an ongoing crisis of legitimacy in the work of mental health nurses. They suggested that despite educational changes over the last two decades there was evidence that service users have difficulty getting time to speak with nurses and that nursing interventions were largely empty of therapeutic content. Interestingly, Bowers, Van Der Merwe, Paterson, and Stewart (2011) suggest that attempts to lessen usage of manual restraint and force could usefully focus on increasing the availability of medical staff to patients, reducing reliance on security guards and establishing a good ward structure. This study suggests that the crisis has not yet been resolved. Restraint and typically restraint of the service user on the floor were embedded within routine mental health practice as a legitimate intervention to deal with a situation exacerbated by organisational constraints and the failure to develop a therapeutic relationship with service users. This study suggests a sense of inevitability about its recurring use in future practice, unless a stronger organisational approach is taken to its reduction. References Bigwood, S. And, & Crowe, M. (2008). It's part of the job, but it spoils the job: A phenomenological study of physical restraint. International Journal of Mental Health Nursing, 17, 215–222. Bowers, L., Van Der Merwe, M., Paterson, B., & Stewart, D. (2011, Jul 6). Manual restraint and shows of force: The City-128 study. International Journal of Mental Health Nursing, doi:10.1111/j.1447-0349.2011.0075. Care Quality Commission (2009). National NHS Patient Survey Programme: Mental Health Acute Inpatient Service Users Survey 2009. London: Care Quality Commission. Charmaz, K. (2006). Constructing grounded theory. A practical guide through qualitative analysis. London: Sage. Chien, W. T., Chan, C. W. H., Lam, L. W., & Kam, C. W. (2005). Psychiatric inpatients' perceptions of positive and negative aspects of physical restraint. Patient Education and Counseling, 59(1), 80–86. Cusack, K. J., Frueh, B. C., Hiers, T., Suffoletta-Maierle, S., & Bennett, S. (2003). Trauma within the psychiatric setting: A preliminary empirical report. Administration and Policy in Mental Health, 30(5), 453–460. Department of Health (2002). Mental Health Policy Implementation Guide. Adult Acute Inpatient Care Provision. London: Department of Health. Exworthy, T., Mohan, D., Hindley, N., & Basson, J. (2001). Seclusion: Punitive or protective? The Journal of Forensic Psychiatry, 12(2), 423–433.
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Frueh, B. C., Knapp, R. G., Cusack, K. J., Grubaugh, A. L., Sauvageot, J. A., Cousins, V. C., et al. (2005). Special section on seclusion and restraint: Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services, 56(9), 1123–1133. Healthcare Commission (2008). National Audit of Violence 2006_7 Final Report _ Working age adult services. London: Healthcare Commission. Hoekstra, T., Lendemeijer, H., & Jansen, M. (2004). Seclusion: The inside story. Journal of Psychiatric and Mental Health Nursing, 11(3), 276–283. Hopton, J., & Glenister, D. (1996). Working in partnership: Vision or pipe dream?: An evaluation of the 1994 review of mental health nursing. Critical Social Policy, 16, 111–119. Huckshorn, K. (2004). Reducing seclusion restraint in mental health use settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42, 22–33. Lancaster, G. A., Whittington, R., Lane, S., Riley, D., & Meehan, C. (2008). Does the position of restraint of disturbed psychiatric patients have any association with staff and patient injuries? Journal of Psychiatric and Mental Health Nursing, 15(4), 306–312. LeBel, J. (2011). Restraint and seclusion prevention in the USA: Core strategies to reduce use and sustain gaps. Paper presented at 7th European Congress on Violence in Clinical Psychiatry 19–22 October 2011 Prague − Czech Republic. LeBel, J., Huckshorn, K., & Caldwell, B. (2010). Restraint use in residential programs: Why are best practices ignored? Child Welfare, 89(2), 169–187. Lee, S., Gray, R., Gournay, K., Wright, S., Parr, A. -M., & Sayer, J. (2003). Views of nursing staff on the use of physical restraint. Journal of Psychiatric and Mental Health Nursing, 10, 425–430. Meehan, T., Bergen, H., & Fjeldsoe, K. (2004). Staff and patient perceptions of seclusion: Has anything changed? Journal of Advanced Nursing, 47(1), 33–38. National Institute for Health and Clinical Excellence (2005). Violence: The short-term management of disturbed/violent behaviour in psychiatric in-patients and emergency department guidelines. London: NICE. NIMHE (2004). Mental Health Policy Implementation Guide: Developing positive practice to support the safe and therapeutic management of aggression and violence in mental health in-patient settings. London: NIMHE. Paterson, B., Bradley, P., & Stark, C. (2003). Deaths associated with restraint use in health and social care: The results of a preliminary survey. Journal of Psychiatric and Mental Health Nursing, 10, 3–16. Pereira, S., Dawson, P., & Sarsam, M. (2006). The National Survey of PICU and low secure services: 2. Unit characteristics. Journal of Psychiatric Intensive Care, 2, 3–19. R (on the Application of AC) –v- Secretary of State for Justice [2008] EWHC 171 (Admin). Robins, C. S., Sauvageot, J. A., Cusack, K. J., Suffoletta-Maierle, S., & Frueh, B. C. (2005). Special section on seclusion and restraint: Consumers' perceptions of negative experiences and “sanctuary harm” in psychiatric settings. Psychiatric Services, 56(9), 1134–1138. Ryan, C., & Bowers, L. (2006). An analysis of nurses' post incident manual restraint reports. Journal of Psychiatric and Mental Health Nursing, 13, 527–532. Sailas, E., & Fenton, M. (2000). Seclusion and restraint for people with serious mental illnesses. Cochrane Database of Systematic Reviews(1) Art. no.:CD001163. Stewart, D., Bowers, L., Simpson, & Tziggili, M. (2009). Manual restraint of adult psychiatric inpatients: A literature review. Journal of Psychiatric and Mental Health Nursing, 16, 749–757. Warner, L. (2005). Acute care in crisis. In A. Bell, & P. Lindley (Eds.), Beyond the water towers: The unfinished revolution in mental health services 1985–2005. London: Sainsbury Center for Mental Health. Wynn, R. (2004). Psychiatric inpatients' experiences with restraint. Journal of Forensic Psychiatry and Psychology, 15, 124–144.
Contents lists available at SciVerse ScienceDirect
International Journal of Law and Psychiatry
Physical restraint in a therapeutic setting; a necessary evil? Elizabeth Perkins a,⁎, Helen Prosser b, David Riley c, Richard Whittington a a b c
Health & Community Care Research Unit, University of Liverpool, UK Centre for Social Justice Research, University of Salford, UK Mersey Care NHS Trust, Liverpool, UK
a r t i c l e
i n f o
Available online 16 December 2011 Keywords: Physical intervention Restraint Coercion
a b s t r a c t Physical restraint of people experiencing mental health problems is a coercive and traumatic procedure which is only legally permitted if it is proportionate to the risk presented. This study sought to examine the decision-making processes used by mental health staff involved in a series of restraint episodes in an acute care setting. Thirty nurses were interviewed either individually or in focus groups to elicit their views on restraint and experience in specific incidents. Four factors which influenced the decision to restrain were identified: contextual demands; lack of alternatives; the escalatory effects of restraint itself; and perceptions of risk. While some of these factors are amenable to change through improvements in practice, training and organisational culture, nurses viewed restraint as a necessary evil, justified on the basis of the unpredictable nature of mental illness and the environment in which they worked. © 2011 Elsevier Ltd. All rights reserved.
1. Introduction Physical restraint of people experiencing mental health problems against their will is an intrusive and risky procedure which is only legally permitted in very specific circumstances. In most jurisdictions, these circumstances include detention under the relevant mental health legislation. Such detention does not, however, eradicate the requirement for the intervention to be proportionate to any risk perceived by the practitioners (NIMHE, 2004). There is an expectation that ‘best practice’ means practitioners will strive to de-escalate behaviour and so avoid restraint whilst maintaining a safe environment. If staff have to use restraint it is expected that they will use the least intrusive method of restraint appropriate in the circumstances. Since physical restraint can range from firmly holding the person's arms whilst they remain standing to forcing the person to the floor and pinning all four limbs down (‘takedown’), there is always a choice to be made about the degree of force even once the decision to implement restraint has been taken. Notwithstanding the drive to establish consistent standards of good practice in this area, such judgements of proportionality and decisions on when to implement physical restraint are highly complex and inevitably somewhat
⁎ Corresponding author at: Health & Community Care Research Unit (HaCCRU), Institute of Psychology, Health and Society, University of Liverpool, Liverpool L69 3GB, UK. Tel.: + 44 151 794 5909(direct line), + 44 151 794 5503(office); fax: + 44 151 794 5434. E-mail address: [email protected] (E. Perkins). 0160-2527/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijlp.2011.11.008
subjective. They have been subject to legal challenge in the UK and elsewhere (e.g. R on the Application of AC –v- Secretary of State for Justice). Coercive physical interventions (PI) such as restraint have been a controversial aspect of psychiatric care since the time of Pinel with a consensus which lasted into the 1990s that such interventions are an inevitable, albeit undesirable, means of ensuring safety. The potential traumatic effects of PI use are well-established (Chien, Chan, Lam, & Kam, 2005; Cusack, Frueh, Hiers, Suffoletta-Maierle, & Bennett, 2003; Frueh et al., 2005; Hoekstra, Lendemeijer, & Jansen, 2004; Lancaster, Whittington, Lane, Riley, & Meehan, 2008; Meehan, Bergen, & Fjeldsoe, 2004; Paterson, Bradley, & Stark, 2003; Robins, Sauvageot, Cusack, Suffoletta-Maierle, & Frueh, 2005; Wynn, 2004). However, it is only recently that a groundswell of opinion has developed in North America, Europe and Australasia over the past decade against the use of PI as a part of everyday mental health care (Huckshorn, 2004). PI, in this new ‘zero tolerance’ thinking, is either always illegitimate by definition, or should be restricted to a very small number of highly risky situations. In the context of a mental health system which espouses core values of collaboration and partnership with service users, PI is viewed as a professional and systems failure requiring intensive scrutiny and executive action. Such a culture shift increases the pressure on practitioners to reflect on their practice in terms of the proportionality of response to the perceived risk. In particular, in relation to this study, the choice between standing (‘vertical’) restraint and ‘takedown’ to the floor (‘horizontal restraint’) is pertinent and worthy of examination. The study on which this paper is based used a recent physical restraint episode as a basis for exploring the attitudes of staff towards
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restraint and as a way of beginning to unpick some of the influences on their decision making and behaviour.
described the attempted balancing and weighing of risks when talking about one new service user who had been making threats of physical assault.
2. Methods Thirty nursing staff working in an acute adult mental health setting in the UK were recruited to the study; of whom, fifteen were interviewed individually, thirteen took part in focus group interviews and a further 2 took part in both. The individual interviews were undertaken in 2007 within two weeks of a restraint episode occurring. They involved a range of nursing staff that included staff nurses and ward managers, on both day and night shifts. The individual interviewees included 9 women and 8 men, who ranged in age from 25 to 56. All respondents had worked in an acute mental health inpatient setting for between 18 months and 25 years. The interview was designed to explore the restraint incident retrospectively, using it also as a basis for discussion of more general views and attitudes on the use of restraint. Both individual interviews and focus group discussions were conducted in a private and confidential location within the mental health trust. All interviews and focus groups were audio-recorded and transcribed verbatim after first gaining the written consent of participants. All quotes have been anonymised or attributed to a pseudonym. Interview and focus group transcripts were read and re-read to identify the main thematic areas. Since the aim of the study was to uncover new insights into the factors influencing restraint, the emphasis was on identifying variation in accounts, rather than in quantifying the frequency of particular types of experience. Analysis began by organising the data into broad domains based on the interview and topic guides. Consistent with a thematic analytic approach (Charmaz, 2006), further themes, categories and subcategories were constructed from the data as analysis proceeded. Categories and themes were explored for consistency and compared within and between transcripts in order to examine variations in responses. Finally, key concepts were identified by re-reading the categorised data and searching for links between each concept. This process also incorporated a search for any anomalous findings, with conceptualisation revised to take account of these. The study was approved by an NHS Research Ethics Committee. 3. Findings In the majority of restraint incidents discussed with staff, the service user was moved to the floor and restrained in a horizontal position. In only 2 incidents the service user was restrained in a vertical (standing) position and in one of these the staff member interviewed stated that a move to the floor would have been preferable had space permitted. Staff identified aggression or violence, self-harm, absconding and the planned administration of medication as the antecedents leading to restraint. There were a number of factors that staff identified which help to explain why restraint is seen as an important intervention within mental health institutions. These will be explored in more detail starting with the contextual demands, moving on to the sense of a restricted range of available options, the escalatory effects of restraint itself and finally perceptions of risk. 3.1. Contextual demands A recurring perception throughout the interviews was that organisational demands and ward factors created the climate in which difficult behaviour developed and escalated. There was recognition that changes in the service user population impacted on the dynamics on the ward. Not just between staff and service users but also between service users. Staff were more cautious in their dealings with individuals who they did not know very well. One staff member succinctly
He has got no history of aggression … but I think his bark is worse than his bite, but I don't know, I have never nursed him before, so I don't know how much he would escalate and when he would back off, if he would, so I don't know, he is a bit of an unknown quantity really. (Interview 17) The sense of knowing an individual, or having built up a relationship with someone and recognizing their behavioural pattern and triggers helped inform staff's expectations of an individual's behaviour and, in particular, the risks posed. If you know a person's potential, and you know what their strengths and weaknesses are and whether you can actually talk somebody round then it's always easier. With somebody who is an unknown, who has a previous recent history of aggression towards family and friends, then you know that this person is more capable and more likely to lash out and hurt somebody, than somebody who has no previous contact, but hasn't got a history. (Interview 6) The use of past behaviour as a predictor of future behaviour provided staff with a frame of reference which in certain circumstances increased the likelihood of de-escalation and decreased the use of restraint. I didn't feel that unsafe because I knew there were two staff with me, because I had got quite a good relationship with him… I didn't feel that threatened. (Interview 16) So if they trust you and you know them, it makes a difference …but if you know someone, you can often spot the triggers, the warning signs, you know the triggers, you know when they're building up to it. (Interview 9) While staff reported that knowing an individual provided a basis for a good relationship and therefore for de-escalation, they felt that staffing levels prohibited the amount of time they had to spend with any one individual. So, while de-escalation was seen as important, staff felt that it was not always possible within the context of their current staffing levels to develop the relationships which made it possible. You would have to spend an awful lot of time talking with them, which is probably time that… while you are spending so much time trying to de-escalate you are actually taking your time away from other patients who probably need your help more than the actual other person. (Interview 10) Ironically, while recognising that preventing a situation from escalating took time, it was also recognised that restraint episodes were also labour intensive, often requiring higher staffing levels and drawing staff from other wards. We had three incidents last night, one was a restraint, one was diffused and one a meds issue, but there was only four staff on the ward so we had to use six additional staff from other wards, which of course leaves them short. (Interview 8) Interestingly, although staff were familiar with de-escalation strategies which focused on neutralising behaviour, (e.g. reducing external stimuli; removing other service users from the area; moving the service user to a safer, or more quiet and private environment; calming the service user by showing signs of listening and acknowledgement of their concerns), in everyday use de-escalation focused
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on communicating with the service user and often directing the service user to modify and contain their behaviour. Paradoxically, communicative de-escalation techniques were deemed to be of least value where a service user was suffering from acute and uncontrollable psychiatric symptomatology. Usually we try and de-escalate it by talking to the patient… but sometimes because they are so unwell, and at the time it could be through hearing voices, or through their illness, could be alcohol or drug abuse, then no amount of talking can actually stop the patient or the service user. (Interview 3) In the context of a changing service user population and what staff perceived to be low staffing levels, it was not surprising that two respondents reported the inconsistent management of service user behaviour as a contributory factor to behaviours leading to restraint. These staff felt that a more objective and consistent approach should be adopted in defining the behaviours to be tolerated, and the steps that should be taken to intervene earlier in managing disruptive and agitated behaviours: I think though that some situations could be avoided, or the potential for situations could be avoided. It's important that the clients know what the boundaries are and that these boundaries should apply to everyone, everyone has to be treated the same. … If some clients are treated differently then that creates tension between staff and clients and it can lead to resentment, frustrations, so behaviours can get difficult. (Interview 8) There was also the sense that the threat of restraint was occasionally used as an alternative to de-escalation but with a view to deterring or modifying behaviour. Again, it was recognised that this in itself might be seen as provocative and have the opposite effect from that intended. I have heard members of staff say, “well don't do that, if you do that, the consequence will be….”, well that, that's provocative to me, that is provocative, that is going to anger a person. (Interview 1) Restraint is used as a means of controlling a difficult patient in difficult circumstances. I think sometimes, and this is just my perception, that sometimes, in reality, it is used as a threat rather than a means of… it's used proactively, rather than reactively I think, that's the best way I can put it. (Interview 14)
3.2. Lack of alternatives While the majority of staff acknowledged the existence of a progressive approach to restraining an individual; with horizontal restraint being the last resort, the reality was that the majority of incidents resulted in horizontal restraint without any intervening positions being tried. In only a small number of incidents was vertical restraint reported to have been used as an initial procedure in a progressive step-wise process. If staff felt that they could control the service user's behaviour and the service user was calming down and becoming compliant with staff directions, then a move to horizontal restraint was seen as unnecessary. In the majority of incidents the service user was reported as either physically assaulting or attempting to assault others physically, or was threatening physical violence against others. If the service user resisted attempts to be restrained and staff felt they were unable to reduce the targeted behaviour in vertical or sitting restraint, then restraint was reinforced by moving the service user to the floor. Well, I know in the C&R (training) you are encouraged not to bring the person down to the floor right away as a matter of course, if you feel
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you don't have to, you can restrain somebody on their feet, or even just sort of half way which is on their knees, most restraints are still brought down to the floor. (Interview 1). Initially he was standing up, as I say we had his arms, trying to get his arms down his side, just to stop him from lashing out and hitting us, that was proving unsuccessful because of his fitness and the excitement of the patient himself, he was quite threatened by this and I think that made him a lot more hostile to us initially. And it finished up we just had to pull him on the floor just to make sure that his legs weren't a problem because of his height. (Interview 6) Acts of actual violent assault or the threat of assault were usually reported to be involved where staff proceeded immediately to horizontal restraint. He was punching me in the head mostly and then he was kicking me as well in the ribs, in the side, my chest and that, and then I fell backwards to the floor, and as I fell backwards to the floor he was …, still punching me and kicking me while I was down on the floor, and I managed, he stumbled a bit, and as he stumbled I just managed to jump up, and while I was waiting for the rest of the staff to come to my assistance, I had to get his head in a head lock and like pull him half way down to the floor and then the rest of the staff responded and he had to be restrained then. (Interview 12) When describing incidents involving a rapid move to the floor, respondents' accounts often suggested that explicit decision-making was overtaken by an instinctive or intuitive response. He just ran right at me and he was, I was sort of like by the door standing up, with my back against the wall, he just ran at me, sort of like with his head down and his arms out, to go to punch me. So instinct really I just protected myself and as he got closer, I grabbed his head and brought his head down, because the lower you bring a person, the more difficult it is for them to punch you. (Interview 4) The notion of protecting the self and others from physical harm or intent was used by the staff as justification for using horizontal restraint. However, it also became clear that within staff accounts there was a sense in which particular triggers elicited standardized responses. For instance, as described above and below, physical assault was likely to trigger a decision to use horizontal restraint in self-defence. I mean personally I don't think any of that training, the C&R, equips you for it, does it? It just helps you after you have got them on the floor to keep them down in a safe way. But before that it's just, that is just, it's them or you isn't it. (Interview 13) The overriding concern when faced with violence and aggression or a perceived intent to harm, was the need to act quickly. This sense of urgency often seemed to result in an unsystematic restraint episode, rather than a graduated, progressive sequence. Describe the way we did it? Well really on restraining and taking someone down, we wouldn't know how it happens because it happens that quick, that you just, it's just a scrap to be quite honest. It is a scrap. I mean you get taught all these methods …It doesn't work. To be quite honest, it's dog eat dog. (Interview 13) There's no training that can ever really portray what it's like to go hands on, and I think the course is really good, but when you actually, when you're in a situation when you're about to restrain someone very seriously, … everyone's adrenalin is going and everyone can just sort of jump in really without there being that control. (Interview 15)
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In these circumstances, the ability to make clear decisions about restraint was over ridden in the eyes of the staff by the need to control the service user's behaviour. We had to use restraint, there was no other option of controlling him. (Interview 12) Throughout the interviews, staff, while recognising the notion of restraint as a means of last resort, viewed it as a ‘necessary evil’, that is a necessary strategy in controlling behaviour and reducing the risk of violence and harm even though the majority of staff talked with dislike about its application. You need it because it's for your safety and other people's safety. Because, you just need it there because if you didn't have it, people could get hurt. I mean I know it's not the nicest thing, and it is uncomfortable, but you have got to look at it, at the safety aspects of what could happen if we don't use restraints. (Interview 2) For the majority of the respondents there was a clear association between mental illness and the service user's inability to control their own behaviour which created the context in which the need for restraint was almost normalised. I just think because of the type of people you are dealing with … I think it's a natural progression, that some people will become aggressive because of their state of mind. (Interview 17) It's driven by mental illness, and basically they are not so much aware of what they are doing, they are not really responsible for what they are doing, and because of their mental illness I think you don't know how far they would go, so they are really dangerous, … some patients you will get, and they are that mentally ill, that psychotic they are constantly hearing voices, telling them to harm people, and so they are the ones who are really unpredictable who I think could, you know, go as far as killing people. (Interview 17) But I think it happens too often as well on our ward anyway lately....we restrain on a daily basis sometimes. (Focus group3; P1) The nursing staff in this study judged that all of the incidents of restraint discussed in the interview had been used appropriately, and, on reflection, considered that little could have been done differently to prevent the incident from occurring. Very few staff reported feelings of disquiet over their own practice in handling the incident after it had finished or after their shift had ended. There was only one respondent who reported that the process itself could have been executed better, but none felt that restraint had been used inappropriately. References to ‘taking control’ formed a central feature in staff's rationalisations of the use of horizontal restraint. This related to one of two conceptualizations: a) restraint as a technique to directly suppress aggressive and violent behaviour; and b) restraint as a management strategy to maintain order and stability within the organisational setting. We had to move her onto the floor because we just couldn't control her on the bed, we were all moving, so the only way we could control her, she was lying face down and there was one on either arm, one on the head, and two on the legs because she was strong, and we had to talk her round for about 45 minutes, she was on the floor. (Interview 2) Actually I have never used the vertical restraint. … you have more control when you take people down to the floor. (Interview 4)
As the above examples demonstrate, horizontal restraint is considered the most expedient and effective means in disempowering the service user and rapidly subduing the targeted behaviour. At the same time, staff rationalised the use of restraint in terms of acting to minimise harm and keep individuals safe. Significantly, however, staff emphasised that whether an individual was restrained horizontally or vertically, or on their front or back was rarely a matter of choice. More often it resulted from a lack of other options. Two situational factors influencing restraint position were cited: space and immediacy. Limitations of physical space and the physical positioning of the service user contributed to the restraint position used. The second dimension to taking control concerned threats to the established order and stability of the ward. The importance of maintaining control over service user's behaviour on the ward was evident in a number of accounts. Threats to the functioning and stability of the ward were important factors in deciding to use restraint, not least because it was recognised by staff that the intensification of agitated and disturbed behaviour could spread across individuals. I mean when you are working on a ward like this, I am always well aware that shouting, screaming, commotions on a ward affects all the other patients on the ward and there is a lot of people here with like anxiety problems and things, so I felt I needed … to calm the situation down. (Interview 17) While the overall safety of the ward environment may be at the heart of such rationalisations, there is an evident tension between maintaining the therapeutic environment and the best interests of the individual service user. 3.3. The escalatory effects of restraint Once restraint is implemented it seems that the end goal is simply an attempt to reduce the undesirable behaviour (crisis intervention), with the specific causes or antecedents to it becoming inconsequential in the effort to take control. However, all staff reported that the physical intervention itself becomes the battleground for control between staff and the service user with each seeking to gain the upper hand. The minute you lay hands on, the incident that originally got you to that point, is lost, it then becomes a situation of well you know, get off me, I will calm down when you get off me, and then the retort from the staff side is well no, when you have calmed down, and the service user then says well I will calm down when you get off me, and it then becomes a stalemate … a service-user, might calm down quicker if the restraint wasn't so long, instead of being forced, as it were, into submission, sort of like we will take hands-off when we feel you have calmed down. (Interview 1) Indeed, while staff reported making efforts to explain the purpose of the restraint to the service user, at the same time, they were highly directive and demanding of the service user. Staff generally considered control of the situation to have been established when the service user exhibited signs of submission and co-operation. She looked at me, she said ‘I fucking hate you, I really hate you’, and the venom in her face was like unbelievable and that's when we kept her down. You know for a fact when they have calmed down. (Interview 13) You know every time you loosen your hold or take any pressure away, if he is trying to get up and fight you then you say, ‘no, just lie still, we don't like to do this anymore than you do, erm, just relax.’ (Interview 6) Respondents acknowledged that service users were not routinely given the opportunity to discuss their experiences following an
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incident of restraint or given a clear explanation of the decision to use restraint. Staff reported that this was generally left to the discretion of staff and was dependent upon an assessment of the service user's mental state and capacity to comprehend.
a point where you feel that any second now instead of being stood against the wall and lashing out with a distance between you, he is going to come at us, and at that point we said like, and that is when we actually put hands on. (Interview 6)
I have never really asked them, I have never actually gone back and said, ‘well ok how do you feel about it?’ Perhaps we should do. (Interview 10)
Although staff report that they assess escalating situations within the context of safety to self and others, not all escalating situations were deemed to be dangerous. Another further element that appears to have an influence on decision-making is individual staff's tolerance of risk and uncertainty. Several respondents recognised that restraint was sometimes used too quickly.
Interestingly the staff also reported the need for debriefing and support following restraint incidents. When a restraint happens…, we don't talk about the restraint, we don't talk about what happens, what we done well, we don't learn about the restraint, we just sort of fuddle on, back onto our jobs, and do what we do again and then a restraint comes again and we do the same thing, we don't learn. (Focus group 1; P 4)
3.4. Perceptions of risk In trying to understand the way in which restraint was used in this secure forensic setting, perceptions of risk emerged as a crucial driver. Risk was regarded as a part of everyday mental health care for the members of staff involved in this study. How risk is played out in this setting is complex. While staff adopted a discourse of risk assessment and progressive de-escalation in their interviews, they also described how perceptions of risky behaviour in practice often triggered a reflex restraint response. Perceptions of risk, however, appear to be formed quickly and intuitively based on responses to actual or attempted physical violence and were also linked to particular situational contexts. One staff member described how a judgement about the use of horizontal restraint was made instinctively after being assaulted in the face. It was almost a reflex action in the sense that you make all these judgements very quickly and the safest thing to do seemed to be to take him straight onto the floor. (Interview 14) When you hear that noise you just drop everything and go and you have got to, because it could be your colleagues in danger, it could be a client in danger, you just, you have got that instinct to just go and see what it is. (Interview 2) Behaviours that are regarded as having high probability of causing significant and immediate harm are instinctively constituted as exposing staff to high risk. This was also clearly the case for behaviours that were seen to erupt without any warning signs. As noted previously, horizontal restraint is seen as a situational necessity in order to minimise the risk of harm and to exert control. If … you were planning that you were going to have to go and restrain someone because, I don't know, they were smashing up the dining room or something, then in those circumstances you would be planning to go in as a team to take them straight to the floor, …because if they were already actually being aggressive and violent, you probably wouldn't take the risk of standing and it demobilises them quicker. (Interview 16) As the above quote suggests, the challenges for staff arise from assessing the risk in various situations, and predicting the outcome and consequences of a situation. An assessment of the concurrent level of threat, the attribution of intent and the interpretation of a given behaviour are critical mediators in making this calculation. I was asking him would he come sit with the Dr, he wasn't having any of it, as I say he started spitting at us and lashing out. And there comes
Sometimes some people go in too hastily I think, instead of just standing back and talking, you know de-escalate, a lot of people think a patient raises their voice, and their arm comes up and get on top of them and I don't think there is any need for that. I mean, sometimes there is a need for it, but I don't think there is a need for it half the time. (Interview 10) Differing degrees of risk tolerance may help explain the variation in restraint procedure that some respondents acknowledged between individuals. Staff surmised that those who they saw as intervening ‘too hastily’, were perhaps fearful and thus overly-cautious, in responding to risk. I mean you know it might be fear of getting smacked, let's just get it over with now and cut down the possibility of getting smacked. (Interview 10) Some staff I feel because of lack of confidence will go in sooner rather than later, because they don't want the situation to escalate, rather than give it time to de-escalate. They would say they are being more pro-active because they feel that the risk was there, that's their assessment. (Interview 6) Clearly, the staff interviewed recognised different perceptions of risk and danger and perhaps more importantly read situations in different ways. There was uncertainty about reliably predicting how events would unfold leading some staff into a physical intervention almost as a pre-emptive strike. Of course this risked creating the situation that staff were keen to prevent — a physical struggle. I don't think you can take the chance to think well maybe they won't strike out again. I don't think you can wait to be hit. I think you just automatically…when someone is actually aggressive towards you, putting hands on keeps everyone safe. (Interview 17) Keeping everyone safe was very much informed by knowledge of a person's behavioural or restraint history. There was little acknowledgement, however, that this view could perpetuate the use of physical intervention as a first line strategy for particular service users who appeared to have a history of violence and aggression. The previous night he'd actually attacked another member of staff and punched him three times in the head, so I was already on alert… We had to take him down to the floor. (Interview 8) As already reported above, there was a common perception that there were clear differences between staff in the way they approached restraint. Personal qualities and individual tolerance levels of aggression and violence were forwarded as explanations of this difference. There are some people who always seem to be involved in C&R and I wonder why that is. The same staff, the names keep cropping up in C&R incidents and I wonder if they're too quick to go hands on rather
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than to continue to try de-escalation and to try other tactics. (Interview 15) There are different staff attitudes and some staff can be aggressive, which doesn't help the situation. If you're highly charged and you've got a member of staff who comes in bluntly, saying ‘calm down’, it can have the opposite effect. Some staff are better at dealing with patients than others, it's their attitude, some people just know how to calm people down better than others. (Interview 9)
4. Discussion The research literature on the use of restraint is quite extensive now but given the difficulties of researching emergency situations is bedevilled by methodological limitations. Although Exworthy, Mohan, Hindley, and Basson (2001) report a role for restraint in the prevention and reduction of disturbed behaviour in a therapeutic setting, a Cochrane Review (Sailas & Fenton, 2000) found no controlled studies that evaluated the effect of restraint or seclusion on those with serious mental illness. Notwithstanding this there appears to be a consensus that the use of physical restraint in psychiatric settings is pervasive. In a recent survey of 307 PICUs and Low secure units in the UK Pereira, Dawson, and Sarsam (2006) reported that the majority used control and restraint as core interventions to manage disturbed behaviour. There is also extensive national guidance in the UK based on the assumption that restraint is an unfortunate but inevitable part of mental health care. This study explored how restraint is viewed and used by staff working in an acute mental health setting. Successful de-escalation and the less intrusive forms of restraint, such as holding the person whilst standing, were less evident in the interviews but had they been present, might have given insight into the successful use of minimal force. Given the small scale nature of this study and its focus on staff in one institution it is perhaps not surprising that there was little discernible difference in the views of staff taking into account their age, gender and clinical experience. Four groups of factors were identified by staff to have influenced the use of restraint; contextual demands; lack of alternatives; the escalatory effect of restraint itself; and; perceptions of risk. The study highlights the complex and sometimes contradictory interaction of variables which were perceived by staff to influence their decision to use restraint. At the same time as talking about the importance of building relationships and trust between staff and service users, staff talked about policy changes which brought new and demanding service users onto the wards leaving them little time to develop relationships and mutual trust. Staff identified a range of techniques for de-escalation but almost exclusively relied upon communicative strategies which they recognised as likely to be the least effective strategy given the service user's mental state. They talked about maximising time with the service user to get to know him/her before crises developed but recognised that the resource-intensive nature of restraint drew staff away from interacting with other service users not involved in the restraint episode. In addition, staff recognised the inconsistencies which existed in the use of restraint with staff holding different thresholds for intervention depending on their perception of the risk posed at the time. They reported situations in which formal risk assessments are overridden by intuition and the need to manage a crisis raising perceptions of personal threat and in so doing triggering restraint. Importantly, staff identified the inherent tensions that exist in acute mental health care provision today as a justification for the continued need for restraint as an intervention. Not surprisingly therefore, whether used as a threat to prevent escalation or as an actual intervention to manage a situation, restraint was viewed as a necessary evil. Other studies also report that nurses see restraint as a necessary part of their job but one that they would like to minimise (Bigwood &
Crowe, 2008). A postal questionnaire survey of 269 nurses in regional secure and psychiatric intensive care units in England and Wales which examined nurses' last experience of using control and restraint (Lee et al., 2003) reported that most nurses (96%) reported positive outcomes of the restraint. However a quarter of respondents also expressed concern about the impact on patients and some found the experience of restraint demeaning and stressful. It is possible that restraint may provide staff with a strategy for resolving the risk ambiguities inherent in working with potentially violent and aggressive individuals. In this study staff reported violence and aggression as major precursors to a restraint episode. This association between the use of restraint and patient violence is reflected in much of the psychiatric literature. However, a study of post-incident manual restraint forms analysed by Ryan and Bowers (2006) found that violence was rarely mentioned as a cause for restraint. The most common reasons related to more general disruptive and challenging behaviours. Stewart, Bowers, Simpson, and Tziggili (2009) suggest that there is a distinction between the causes entered on incident forms and the factors which determine the management of an incident. Whilst this is a possible explanation of the difference it does raise questions about the factors which influence the way in which restraint episodes get recorded and why disruptive and challenging behaviours result in restraint. The most recent National Audit of Violence within Working Age Adult (Psychiatric) Services (Healthcare Commission, 2008) reported an increase in the nature, level and severity of violence on wards. The authors also stated that the ‘effectiveness with which staff teams prevent and manage incidents has also increased’, with ‘clear evidence that the majority of services are now adopting proactive and preventive strategies to tackle violence in inpatient services’. The staff interviewed in this study had been trained to use Physical Intervention and saw it as a way of preventing individuals from “harming themselves, endangering others or seriously compromising the therapeutic environment” (National Institute for Health & Clinical Excellence, 2005:9). What is not clear from the study is how and indeed whether, this training had an impact on the proportionality of the restraint imposed in relation to its antecedents and on the frequency with which staff use this form of intervention. Given the complex nature of the use of restraint it cannot be assumed that improved training on its own will reduce the incidence of restraint. Health services in the United States have been actively working on reducing and preventing restraint, driven, according to LeBel (2011), by a number of largely unreported deaths arising from both restraint and seclusion. Widespread adoption of the Six Core Strategies model appears to offer the opportunity for a more holistic organisational alternative to the reliance on coercive interventions than does the implementation alone of training programmes for individual members of staff and care teams. The six elements are; (i) leadership towards organisational change (ii) using data to inform practice (iii) workforce development (iv) use of seclusion/restraint prevention tools (v) consumer roles in inpatient settings and (vi) debriefing. Nine years after the first implementation of the Six Core Strategies model, LeBel, Huckshorn, and Caldwell (2010) have reported a number of success stories. Not only has the number of restraint/seclusion episodes decreased in a number of services in which it has been implemented but also a range of other benefits have been reported. Most notably these include a reduction in staff turnover, staff injuries, absenteeism and retraining costs (LeBel, 2011). These six elements appear to offer staff and patients support in creating and sustaining a therapeutic environment on an ongoing basis. It does however require substantial commitment from all levels of the organisation based on a recognition from the top down of the systemic nature of the problems which underpin the frequency with which restraint is used. Contrary to the rhetoric of partnership working in which service users are active participants in their own treatment and nurses have
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a clear therapeutic role, the nurses in this study expressed a resigned acceptance of the conditions and limited options which they felt gave rise to the need for physical intervention. This may reflect broader problems in terms of the purpose and success of both acute in-patient services in general (Warner, 2005) and mental health nursing in particular. Numerous reports have identified the therapeutic poverty of many acute wards and the attendant problems of boredom and frustration (Care Quality Commission, 2009; Department of Health, 2002). Hopton and Glenister (1996) reported an ongoing crisis of legitimacy in the work of mental health nurses. They suggested that despite educational changes over the last two decades there was evidence that service users have difficulty getting time to speak with nurses and that nursing interventions were largely empty of therapeutic content. Interestingly, Bowers, Van Der Merwe, Paterson, and Stewart (2011) suggest that attempts to lessen usage of manual restraint and force could usefully focus on increasing the availability of medical staff to patients, reducing reliance on security guards and establishing a good ward structure. This study suggests that the crisis has not yet been resolved. Restraint and typically restraint of the service user on the floor were embedded within routine mental health practice as a legitimate intervention to deal with a situation exacerbated by organisational constraints and the failure to develop a therapeutic relationship with service users. This study suggests a sense of inevitability about its recurring use in future practice, unless a stronger organisational approach is taken to its reduction. References Bigwood, S. And, & Crowe, M. (2008). It's part of the job, but it spoils the job: A phenomenological study of physical restraint. International Journal of Mental Health Nursing, 17, 215–222. Bowers, L., Van Der Merwe, M., Paterson, B., & Stewart, D. (2011, Jul 6). Manual restraint and shows of force: The City-128 study. International Journal of Mental Health Nursing, doi:10.1111/j.1447-0349.2011.0075. Care Quality Commission (2009). National NHS Patient Survey Programme: Mental Health Acute Inpatient Service Users Survey 2009. London: Care Quality Commission. Charmaz, K. (2006). Constructing grounded theory. A practical guide through qualitative analysis. London: Sage. Chien, W. T., Chan, C. W. H., Lam, L. W., & Kam, C. W. (2005). Psychiatric inpatients' perceptions of positive and negative aspects of physical restraint. Patient Education and Counseling, 59(1), 80–86. Cusack, K. J., Frueh, B. C., Hiers, T., Suffoletta-Maierle, S., & Bennett, S. (2003). Trauma within the psychiatric setting: A preliminary empirical report. Administration and Policy in Mental Health, 30(5), 453–460. Department of Health (2002). Mental Health Policy Implementation Guide. Adult Acute Inpatient Care Provision. London: Department of Health. Exworthy, T., Mohan, D., Hindley, N., & Basson, J. (2001). Seclusion: Punitive or protective? The Journal of Forensic Psychiatry, 12(2), 423–433.
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Frueh, B. C., Knapp, R. G., Cusack, K. J., Grubaugh, A. L., Sauvageot, J. A., Cousins, V. C., et al. (2005). Special section on seclusion and restraint: Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services, 56(9), 1123–1133. Healthcare Commission (2008). National Audit of Violence 2006_7 Final Report _ Working age adult services. London: Healthcare Commission. Hoekstra, T., Lendemeijer, H., & Jansen, M. (2004). Seclusion: The inside story. Journal of Psychiatric and Mental Health Nursing, 11(3), 276–283. Hopton, J., & Glenister, D. (1996). Working in partnership: Vision or pipe dream?: An evaluation of the 1994 review of mental health nursing. Critical Social Policy, 16, 111–119. Huckshorn, K. (2004). Reducing seclusion restraint in mental health use settings: Core strategies for prevention. Journal of Psychosocial Nursing and Mental Health Services, 42, 22–33. Lancaster, G. A., Whittington, R., Lane, S., Riley, D., & Meehan, C. (2008). Does the position of restraint of disturbed psychiatric patients have any association with staff and patient injuries? Journal of Psychiatric and Mental Health Nursing, 15(4), 306–312. LeBel, J. (2011). Restraint and seclusion prevention in the USA: Core strategies to reduce use and sustain gaps. Paper presented at 7th European Congress on Violence in Clinical Psychiatry 19–22 October 2011 Prague − Czech Republic. LeBel, J., Huckshorn, K., & Caldwell, B. (2010). Restraint use in residential programs: Why are best practices ignored? Child Welfare, 89(2), 169–187. Lee, S., Gray, R., Gournay, K., Wright, S., Parr, A. -M., & Sayer, J. (2003). Views of nursing staff on the use of physical restraint. Journal of Psychiatric and Mental Health Nursing, 10, 425–430. Meehan, T., Bergen, H., & Fjeldsoe, K. (2004). Staff and patient perceptions of seclusion: Has anything changed? Journal of Advanced Nursing, 47(1), 33–38. National Institute for Health and Clinical Excellence (2005). Violence: The short-term management of disturbed/violent behaviour in psychiatric in-patients and emergency department guidelines. London: NICE. NIMHE (2004). Mental Health Policy Implementation Guide: Developing positive practice to support the safe and therapeutic management of aggression and violence in mental health in-patient settings. London: NIMHE. Paterson, B., Bradley, P., & Stark, C. (2003). Deaths associated with restraint use in health and social care: The results of a preliminary survey. Journal of Psychiatric and Mental Health Nursing, 10, 3–16. Pereira, S., Dawson, P., & Sarsam, M. (2006). The National Survey of PICU and low secure services: 2. Unit characteristics. Journal of Psychiatric Intensive Care, 2, 3–19. R (on the Application of AC) –v- Secretary of State for Justice [2008] EWHC 171 (Admin). Robins, C. S., Sauvageot, J. A., Cusack, K. J., Suffoletta-Maierle, S., & Frueh, B. C. (2005). Special section on seclusion and restraint: Consumers' perceptions of negative experiences and “sanctuary harm” in psychiatric settings. Psychiatric Services, 56(9), 1134–1138. Ryan, C., & Bowers, L. (2006). An analysis of nurses' post incident manual restraint reports. Journal of Psychiatric and Mental Health Nursing, 13, 527–532. Sailas, E., & Fenton, M. (2000). Seclusion and restraint for people with serious mental illnesses. Cochrane Database of Systematic Reviews(1) Art. no.:CD001163. Stewart, D., Bowers, L., Simpson, & Tziggili, M. (2009). Manual restraint of adult psychiatric inpatients: A literature review. Journal of Psychiatric and Mental Health Nursing, 16, 749–757. Warner, L. (2005). Acute care in crisis. In A. Bell, & P. Lindley (Eds.), Beyond the water towers: The unfinished revolution in mental health services 1985–2005. London: Sainsbury Center for Mental Health. Wynn, R. (2004). Psychiatric inpatients' experiences with restraint. Journal of Forensic Psychiatry and Psychology, 15, 124–144.