Information on this page has been adapted from the Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (2nd edition). Show
Developers: Marel C, Mills KL, Kingston R, Gournay K, Deady M, Kay-Lambkin F, Baker A, Teesson M. (2016). B6: Aggressive, angry or violent behaviour. In Guidelines on the management of co-occurring alcohol and other drug and mental health conditions in alcohol and other drug treatment settings (2nd edition), pp. 181-182. Sydney, Australia: Centre of Research Excellence in Mental Health and Substance Use, National Drug and Alcohol Research Centre, University of New South Wales. The Guidelines were funded by the Australian Government Department of Health and Aged Care. Further information about managing phases of aggression can be found in the Guidelines. Costs: Free Year: 2016 Evidence base: These guidelines were developed based on comprehensive reviews of the best available evidence at the time of development. View the full list of references. Int J Community Based Nurs Midwifery. 2014 Jan; 2(1): 20–30. Background: The use of physical restraint as an intervention in the care of psychiatric patients dates back to the beginning of psychiatry. Although it is a challenging question, it is still one of the common procedures in
psychiatry. Considering that very little research has been done in Iran in relation to physical restraint, this qualitative study aimed to investigate the experiences of nurses working in psychiatric wards regarding physical restraint. Methods: This qualitative study was done on 14 nurses working in the psychiatric hospitals of Ahvaz city, southern Iran, during 2011-2012. The participants were selected by purposive sampling. Semi-structured interviews
were used for data collection, which were continued until data saturation and emergence of themes. Inductive content analysis was used to analyze the data. Results: Four categories emerged: (1) Restraint as a multi-purpose procedure, (2) Processing of physical restraint, (3) Restraint as a challenging subject and (4) The effects of restraint on the spectrum. Each category has several different sub-categories. Conclusion: The
participants described using physical restraint as one of the main strategies to control psychiatric patients, and despite having negative consequences, it is extensively used. Given the risks and challenges of using physical restraint, nursing education should find alternative methods. Keywords: Physical Restraint, Mental Illness, Nurses, Psychiatric Ward, Iran The use of
physical restraint as an intervention in the care of psychiatric patients dates back to the beginning of the science of psychiatry.1 However, it is still one of the challenging questions in the psychiatric services2 and has always been considered as a moral
argument.1 Physical restraint includes devices designed to limit a patient’s physical movements such as limb holders, safety vests and bandages. It is used to handle violent and maladaptive behaviors,3 manage patients with severe mental
disorders,4 prevent injury and reduce agitation and aggression.3 This controlling intervention, which has been inherently designed to protect patients from harm to themselves or others, is associated with many potential
complications. Studies have shown the negative effects of physical restraint on both patients and personnel.5 Some of these effects in patients include risks of physical injury and death,6 negative emotional impact on the patients and their
family members,7 experiencing psychological distress,5 further stimulation of aggression and damage to therapeutic alliances between the patients and the
staff.8 On the other hand personnel are at risk of physical injury, emotional effects, and death.7 Although this intervention can be effective as a last resort in preventing injury to patients and maintaining their security,
it is considered to be traumatizing to patients and contrary to treatment principles and patient dignity.6 Thus the use of coercive interventions is one of the indicators of the quality of psychiatric treatment in hospitalized patients, and many attempts have been conducted in different countries for early prevention together with alternative interventions
to reduce and eliminate the use of these approaches.6 Despite extensive literature on the potential complications of using physical restraint, it is still considered as a permanent and effective intervention in the management of unpleasant behaviors on acute and long-term care
environments.9 Studies show that in many countries more than 20% of psychiatric patients are restrained physically in a period during their hospitalization.6 Researchers who have tried to understand and explain the use of physical restraint in
psychiatric institutions, have identified several predictor variables in the use of restraint. These variables include: poor staff and facility standards, inadequate training of staff, poor education level of staff, inadequate treatment programs, staff’s attitude about physical restraint, and hospital management.10 Moreover, clinical factors such as demographic characteristics or
diagnosis of patients are also influential.11 In general, empirical studies have shown that the rate, duration and application of seclusion and physical restraint are different in various psychiatric hospitals even under the same operational policies and
guidelines.12 Numerous qualitative studies have been conducted on the use of physical restraint. In an ethnographic study, Marangos-Frost and Wells studied the psychiatric nurses’ thoughts and feelings about the use of physical restraint. The results identified four themes: (1) framing of the situation (potential for imminent harm), (2) unsuccessful search for
alternatives to physical restraint, (3) conflicted nurse, and (4) contextual conditions of restraint. The results also indicated that the use of restraint is more complex than is currently conveyed in the literature. They suggested that further investigation was necessary to draw definitive conclusions about the continued use of physical restraint in the care of patients in psychiatric
units.13 Very few studies have been conducted in Iran about the use of physical restraint in psychiatric wards. However, according to the researchers’ experiences, the use of physical restraint in the psychiatric wards of Iran to control violent and non-adaptive behaviors of patients is common. In a study in Iran, the researchers compared the nurses’
physical restraint methods with the existing standards in psychiatric wards. While emphasizing on the popularity of physical restraint for controlling the patients’ violent behaviors, they reported that the principles of physical restraint of patients in Iran are far from the related standards.14 Given the conflicting results of quantitative studies about the related
factors of restraint7 and the importance of conducting qualitative studies for the better understanding of a phenomenon,15 and also according to another study, the use of physical restraint is still common and should be the focus of further
research.16 Since the documentation focusing on seclusion and restraint of patients can be important to provide information for planning alternative models6 and that very little research has been conducted in relation to physical
restraint in Iran, we aimed to investigate the psychiatric nurses’ experiences of using physical restraint in the psychiatric wards of Ahvaz hospitals, southern Iran. This qualitative content-analysis study was conducted during 2011-2012. The inclusion criteria for selecting the participants were: 1- Have a bachelor degree or higher in nursing, 2- Having at least 6 months of work experience in psychiatric
wards, and 3- Willingness to participate in the study. Ultimately 14 nurses of four psychiatric hospitals, with a bachelor’s degree or higher in nursing, were selected using the purposive sampling method. Data Collection and Analysis Audio-recorded, face-to-face, semi-structured interviews were used for data collection. The key question was: “What is your experience of physical restraint in this ward?” All of the recorded interviews were
listened to carefully during the 24 hours after recording and transcribed. The duration of interviews was between 30 to 50 minutes. The interviews were conducted by the first author in Persian language, which were then translated into English. The data collection and analysis preceded concurrently using inductive the content analysis approach. For this purpose, the interviews were transcribed verbatim. After reading the interviews several times, they were divided into meaning units, and after
condensation, the condensed meaning units were abstracted and labeled with codes. The codes, based on similarities and differences, were classified into sub-categories and categories. Finally, based on the underlying main idea of the interviews, main categories or themes were extracted. Data collection continued until data saturation and emerging of themes.17 To verify the validity (credibility) of the obtained data, the following measures were adopted: 1- prolonged engagement and meetings with the participants, 2- repeated reading of the interviews and drowning in the data, 3- using comments and suggestions of the colleagues to verify categories and 4- finally, returning the coded interviews to some of the participants to attain the consensus among the researchers and the participants in the codes. Ethical
Considerations The Ethics Committee of Ahvaz Jundishapur University of Medical Sciences approved the study. Formal authorization was obtained from the College of Nursing and Midwifery of Ahvaz Jundishapur University of Medical Sciences and the hospitals for both the sampling and the study. Both the purpose and method of the research were described for the participants, and written informed consent to participate in the study was received from all of them. The participants in the study were 14 nurses with a mean±SD age of 40.42±8.58 (range: 25-52 years), who had a work experience in nursing of 7 months to 29 years, and experience in the psychiatric wards from 7 months to 26 years. The data analysis revealed four main categories: (1) Restraint as a multi-purpose procedure, (2) Processing of physical restraint, (3) Restraint as challenging subject and (4) The effects
of restraint on the spectrum. Each category or theme has different sub-categories and minor classes (table 1). Themes, categories and sub-categories of psychiatric nurses experiences of physical restrain in psychiatric ward
DiscussionNurses in the psychiatric wards provide care for the patients in an environment with a potential of stress and a lot of violent and non-adaptive behaviors. To cope with such stresses and behaviors, they use a variety of therapeutic and even non-therapeutic approaches. One of these approaches is physical restraint. In this study, the experiences of 14 psychiatric nurses of psychiatric hospitals in Ahwaz, Iran were studied. The first theme is “restraint as a multi-purpose procedure. It appears that physical restraint is of the main nursing interventions to manage and control the patients in psychiatric wards. It is used with different purposes, including the positive attitude of the nurses to this procedure. Nurses’ attitude to physical restraint is considered as one of the main reasons for the various uses of this approach.18 Among the applications of physical restraint is to use it as a means to control high-risk and aggressive patients. Generally, management of non-adaptive behavior, according to the participants, is one of the main applications of this procedure. Application of physical restraint as a means to control non-adaptive behavior of patients has been emphasized in several studies. These studies report that coercive tools are mainly used as a means of control in situations where a patient’s violent behavior threatens the safety of others.19 Moreover, “treatment auxiliary” is of other various applications of restraint, in which physical restraint is used as an auxiliary device until the onset of the therapeutic effects of sedative drugs in some patients. In addition, according to a participant, in cases such as obsessive-compulsive symptoms in the patients, the nurse uses restraint as a way to cope with these symptoms; this helps the patients to control their obsessive behavior. Coercive interventions are used not only to help, treat or cure but also to control the psychotic patients.19 Physical restraint can also be used for helping psychiatric patients who are unable to control their emotions and behaviors.20 The second theme, “processing of restraint”, is of the nurses’ physical restraint approaches, which includes three general stages: actions before, during and after the restraint. “Before restraint” action includes assessment of the patient to restrain or not. It mainly consists of determining the necessity of physical restraint of a patient. Therefore, the nurse, using his/her experience and intuition, and also according to the diagnosis of the patient’s disorder, defines a patient’s need for restraint. Learning to identify when physical restraint is the only safe method is an important skill for the nurses in mental health care institutions.21 The diagnosis associated with rapid restraining of the patient in this study was antisocial personality disorder. Other researchers reported that most of the restrained patients were diagnosed as having schizophrenia, personality disorder, acute psychosis, mania, and substance abuse.22 “Preparing the patient” that includes injecting of tranquilizers to reduce resistance in the patient, is one of the other actions before the restraint. Injection of psychotropic drugs is another options for dealing with an emergency situation to calm down the patients during aggression or provocation.23 In the study of Reghabi, restrained adults and adolescents received a PRN medication before the restraint. “Action during the restraint”, as another stage of restraint, in highly important in the proper implementation of the process. Approaches of nurses in this stage include surrounding the patient, reducing his/her resistance, and safety restraint of the patient in order to minimize the possible damage to both the patients and the staff. For this purpose, nurses apply methods such as using more persons to restrain the patient, distracting the patient’s thoughts, and attempting to restrict the movements of his/her limbs simultaneously while considering the safety of restraint and reducing harm to the patient. During the physical restraint, two main goals are to be met for successful intervention: First, the physical security of the patient, other patients and care providers must be preserved. The second goal is that the patient’s dignity, humanity and comfort throughout the procedure of restraint must be advocated actively.21 Nevertheless, in attempting to reduce resistance and safety restraint of the patient, the nurses in the present study used non-standard approaches, including the use of non-nursing staff, violent restraint of the patient, and also using ordinary facilities and equipment. These approaches to physical restraint were fundamentally affected by nursing shortage in the ward. It is argued that using physical restraint, mainly due to improper applying of techniques and inadequate understanding of the needs of patients, may not be affective in ensuring the patient’s safety and comfort.3 Therefore, all staff in acute psychiatric care wards require excessive knowledge about the policies and procedures related to the use of restraint.21 In a study in Iran, there were significant differences between the performance of nurses in restraining the patient and the existing standards. The process of physical restraint continues even after the restraint of the patient. It includes nursing care, interaction to assess the patient to ensure prevention of damage to him/her, interaction with the patient for the commitment and release of restraint and also explaining to the patient about the reasons and the need to restrain him/her. Chien and colleagues (2005) believe that a licensed employee should assess the need for restraint in an hour of practice, and the patient should be continuously monitored by the personnel during the restraint and evaluated to remove the restraint as soon as possible. The third theme is “restraint as challenging subject”. Restraint as a physical intervention has aggressive and unpleasant nature and, obviously, its application in patients is often associated with some challenges. “Removing of restraint” is one of these challenges discussed by the participants. This occurs mainly due to restraining the patient to the bed and next to other patients, and also applying non-standard tools such as using band for restraint. While, according to the researchers, use of appropriate and standard tools is necessary for physical restraint of the patients.21 Of other challenges associated with the restraint is “the patient’s opposition or resistance” against it, which occurs because of the restrictive nature of restraint and the patient’s perception of being punished. Restraint process is considered as intensive physical intervention for patients.21 Studies have shown that many patients have reported mechanical restraint and seclusion as a negative intervention, a punishment and even a form of retribution.12 These views of patients can underlay their opposition and resistance to restraint. The last theme derived is the “the restraint effects on the spectrum” that includes negative and positive effects. Negative effects include damage to the relationship, damage to patients and affected nurse. Several studies have shown adverse effects of restraint. In fact, one of the reasons of opposition to this procedure is unpredictable incidence of damage and complications in both the patient and nurse.10 Restraint increases the risk of physical damage and even death in patients and is of the most common causes of personnel damage.6 In addition, this situation, according to some participants, is a dilemma that affects nurses emotionally and mentally. Marangos-Frost and Wells reported physical restraint as a decision dilemma.13 One important issue among the consequences of restraint is the potential damage of this procedure on the nurse-patient relationship. Often psychiatric care is dependent on an alliance between the patients and the staff, and use of restraint or seclusion can affect this therapeutic alliance.24 Another outcome associated with restraint is the “positive effects of care”. These effects are incentives for continued use of restraint, and despite the complications and ethical challenges associated with restraint, they are also the causes of staff’s positive attitude toward this approach. There are few studies showing the positive effects of physical restraint.25 It is believed that physical restraint is a method to control people externally in order to make them learn. To some extent, it has internal control over their socially acceptable behavior.26 However, the idea that inhibition can never be a therapeutic tool needs more evaluation.21 The limitation of this study includes the small sample size, which ended with limited applicability of the results. ConclusionThe nurses participating in this study expressed physical restraint as one of the main strategies to control and manage psychiatric patients. Although this method is not to the satisfaction of neither patients nor nurses, nurses are inevitably forced to use it. 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The restraint should not be too tight or too loose. The nurse should check the client's circulation and ensure that there is room to insert two finger-widths between the restraint and the client.
Which legal implication would the nurse understand about applying restraints to a client?If a nurse uses restraints without a legal warrant on a client, he/she may be charged with false imprisonment. Libel is the written defamation of character. Negligence is any conduct that falls below the standard of care. Malpractice is a type of negligence that is regarded as professional negligence.
What are the guidelines that nurses should follow when considering restraints ATI?What are the guidelines that nurses should follow when considering whether or not a client requires restraints? Use a restraint when there is no other option and use the least restrictive restraint first.
Which of the following is considered the most restrictive restraint?Seclusion is considered a "most restrictive" restraint.
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