Using restraint with restraint: A reflection
Eimear Muir‐Cochrane · 2018 · International Journal of Mental Health Nursing · Open access
A peer support worker responded to my query about what nurses could do to improve care with people who were acutely mentally unwell and exhibiting disturbed behaviour. ‘Use restraint with restraint’ was his response, a sage response to a complex, disturbing, distressing practice for all concerned but containment that is necessary as a last resort in care, to maintain safety for nurses, consumers, visitors, and health professionals alike. We know that the international literature tells us that seclusion and restraint are not therapeutic in any way, and there are many reports of adverse outcomes (World Health Organization (WHO) 2017). It is also known that all forms of restraint are associated with physical and psychological deleterious effects on consumers leaving them traumatized, worthless, punished, trapped, and bored (Van der Merwe et al. 2013). The mission to reduce all forms of restraint is, however, complicated, particularly given the incidence of aggression and violence in the workplace. In a co-authored editorial for this journal last year, Joy Duxbury and I commented that aggression and violence are now a global concern in mental health settings. Between 8% and 38% of health workers continue to suffer physical violence at some point in their careers (Muir-Cochrane & Duxbury 2017; WHO 2017). The Royal Melbourne Hospital recently reported an increase in code grey incidents of 85% in 4 years. The situation has become so urgent that emergency department staff at the hospital produced a video, which they play in the waiting area to raise awareness about violence in the workplace. They are also encouraging staff to use an ‘opt-out’ method where they can hand over care of an aggressive individual to other staff as part of a raft of other increased security measures. How such a strategy pans out will be interesting to observe. The regulation of restrictive practices is inconsistent across Australia which adds to the complexity of discussions about the pursuit of least restrictive inpatient psychiatric care. Some Mental Health Acts provide specific provisions to the use of seclusion and restraint (SA, WA, Qld, for example). Other states regulate practice through policy directives not mental health law (e.g. NSW). In terms of policy and reports, Australia and New Zealand have proliferated documents with alacrity since the early 1990s, with recent publications from the National Mental Health Commission (2016) ‘Reducing Seclusion and Restraint’ and the 2017 Te Pou (2017) report ‘Variation in District Health Board Seclusion rates’. The former document clearly demonstrates that the consumer experience of inpatient care and restrictive practices was poor, and in the latter, the wide variation in seclusion rates across New Zealand could not be explained by the demographics of the population the hospitals served, concluding that unit culture was the core factor in using less or more restraint in acute inpatient units. Cultures that are rigid and risk-averse are more likely to result in higher containment rates and atrophy opportunities for innovation towards least restrictive environments. Culture eats strategy for breakfast, so if cultural change is not seriously pursued, improvements in care and restraint reduction will be short-lived at best or nonexistent altogether. Containment cultures occur because organizational structures which enforce risk assessment as the dominant discourse steer practice rather than nurses pre-empting what practices ought to occur (Cleary et al. 1999). While the justification for a focus on risk is safety, there is increasing discussion about the negative effects of a risk approach to consumers in acute inpatient care with Slemon et al. (2017) stating ‘(in) current psychiatric inpatient environments, safety is maintained as the predominant value, and risk management is the cornerstone of nursing care. Practices that accord with this value are legitimized and perpetuated through the safety discourse, despite evidence refuting their efficacy, and patient perspectives demonstrating harm’. It takes time to change practice to reflect the latest evidence, but this is exactly the challenge for mental health nurses in acute inpatient units today. Health professionals create the culture on inpatient units and have to be accountable for their practice, to implement change and the provision of best possible care. Perhaps consideration of the use of sedation (chemical restraint) as a less unpalatable form of containment than mechanical restraint and seclusion is a useful one. Using sedation may seem a somewhat better option for consumers, particularly in EDs where the environment provides additional challenges for consumers, carers, and staff. There is no current nationally agreed definition of what chemical restraint constitutes although there is a multigovernment standing committee working on this. However, after recent sentinel events in the combination of the use of physical restraint and midazolam with agitated and aggressive consumers, medical professionals have called for caution in the use of midazolam when combined with physical restraint due to high respiratory suppression effects. Midazolam is commonly used in Australia in combination with restraint, but guidelines and clinical protocols vary considerably and education and training of staff is often lacking. Thus, the use of chemical restraint presents its own problems, leaving nurses and health professionals stuck between a rock and a hard place in managing aggressive and violent consumer behaviour in often unsuitable clinical environments providing care with limited resources. Georgieva et al. (2012) reported that consumers who had experienced seclusion preferred forced medication over isolation, whereas consumers who had never experienced seclusion favoured medication. Thus, individualized consumer choice (albeit a Hobson's choice) is important but is determined by factors such as previous exposure to containment that need to be factored in to decisions about the choice of restrictive practices. There is no one-size-fits-all. Just as it is now recognized that sex and gender is not binary, discourses around the reduction of restraint in forms need to consider what is possible on a continuum of restrictive practice. ‘Trying to do the least, worst thing’ seems like a sensible option when some form of restraint, be it mechanical, chemical, or physical, may need to be used. Consumer safety plans can help personalize care for individuals and express preferences in regard to how they are cared for when acutely disturbed. Staff prepared in the theory and practice of trauma-informed care are better equipped to have empathy towards disturbed consumers and seek to problem-solve in a patient-centred manner. The research we conducted found that consumers viewed empathy by nurses in different ways to that of nurses’ perspectives. Consumers viewed nurses as empathic when they felt the nurse to be ‘with them’ while they were acutely unwell but also when they perceived nurses to acknowledge them as individuals beyond their illness and current hospitalization (Gerace et al. 2018). I had the good fortune to work with a delegation of nongovernment health professionals earlier this year looking at how to reduce ‘pasung’ in their communities in West Java. Pasung is the restraint of individuals by family in villages and small communities where the behaviour of the person is seen to be unsafe and they are tethered to beds or locked up in outhouses or cages. In theory, pasung is illegal but still practised, and not reported by authorities (as it is illegal, it cannot formally exist). Families do not feel they have any other alternative and beliefs about spirit possession explaining what is seen as abnormal or bizarre behaviour are common. I was questioned at length about how to eliminate pasung. We decided one way forward was for clinicians to begin to work more closely with the village faith healers to educate families and provide alternatives to restraint including practical support. The bridge between faith healers, health professionals, and nongovernment mental health organizations could lead to increased assessment and treatment by mental health professionals and the provision of medication. This approach is more likely to assist families and their loved ones with a mental illness, using existing social and community supports rather than a purely medically based approach. In closing, this opinion will not solve the complex issues about the use of containment practices in acute psychiatric units, but such reflections are vital to progress the cause. The sustained scrutiny on seclusion and restraint in the last decade has resulted in national mandatory reporting of seclusion data and national principles to which the workforce must adhere. The extent of the use of seclusion is now transparent nationally and overseas and will facilitate further efforts towards best practices in least restrictive care.