On restrictive practices: Care and culture
Eimear Muir‐Cochrane · 2018 · Journal of Psychiatric and Mental Health Nursing · Open access
Since 2017, the Australian Institute of Health and Welfare has published national data about the use of restrictive practices in specialized public mental health services. Such practices include seclusion (confinement of a patient at any time of the day or night alone in a room or area from which free exit is prevented) and restraint (including physical restraint, e.g., the use of hands on immobilization techniques by staff, and mechanical restraint, e.g., using devices such as belts or straps). In Australia, rates of seclusion have fallen over the last decade, with current average rates of 7.4 per 1,000 bed days (Australian Institute of Health and Welfare 2018). From 2012–2013 to 2016–2017, the annual reduction in the rate of national seclusion events was 6.7% (AIHW 2018) and many countries are now reporting decreasing rates of seclusion. Annual publication of such data increases the visibility of types of restraint and seclusion and may further facilitate the need for sustained scrutiny on restrictive practices and continue to focus efforts to reduce their use. Of concern in these figures is the fact that many patients are exposed to more than one form of restraint during a single restraint episode and the trauma that such experiences can evoke. The Towards Elimination of Restrictive Practices Australian national forum is a biennial meeting attended by consumers, carers, academics, researchers, clinicians, managers and national professional leaders, where the goal of actively eliminating all forms of restraint, including physical and mechanical, and seclusion is being pursued. While such a goal is admirable, this causes me concern. What will nurses do if they cannot physically restrain someone, as a last resort, to protect the safety and dignity of all concerned? Consumers deserve and expect to be protected and cared for when acutely unwell, even if that means they are contained in some way to maintain safety. Thus, while I applaud ongoing restraint reduction measures, containment of acutely unwell psychiatric consumers will persist as a safety component of inpatient care in one form or another. There remain significant barriers to the implementation of practices to reduce restrictive practices across Australia. I undertook a project for the Australian College of Mental Health Nurses (ACMHN) and the National Mental Health Commission in 2017, looking at the barriers and enablers to reducing restraint practices with people with mental health problems, as perceived by registered nurses in emergency departments and mental health nurses in acute psychiatric units (ACMHN 2017). Findings from this national online survey of over 500 respondents demonstrated that while overall nurses felt confident in working with hostile and aggressive consumers, 94% of nurses agreed that “really threatening situations can occur in the workplace.” 67% of mental health nurses reported that they did not agree that seclusion could be eliminated on their unit. A further 31% of nurses said they did not feel safe around aggressive consumers and 27% were not confident in their colleagues’ ability to manage aggressive situations (ACMHN 2017, Muir-Cochrane, O'Kane, & Oster, 2018). Respondents reported that their concerns about personal safety, skill mix and staffing constrained their ability to deliver trauma-informed care. In Australia, trauma-informed care has been adopted as a way of providing more sensitive and trauma-informed care to achieve optimal outcomes for people using mental health services. Person-centred care approaches seek to facilitate practitioners’ recognize behaviours by individuals which are related to previous trauma and provide interventions which avoid potential retraumatization for the person. The use of restrictive interventions is often traumatizing for individuals and staff involved and can impact on the individual's willingness to re-engage in such services. A trauma-informed and person-centred approach in acute psychiatric units can facilitate a culture of care in the context of restrictions on a person's movements. Trauma-informed care is underpinned by the key principles of safety, collaboration, empowerment, trustworthiness and choice (Fallot & Harris, 2009). This approach also conveys a message of hope and recovery, of what the individual can be and not their presenting symptoms. However, a cultural and philosophical shift is required for services to become trauma-informed. Recent research has demonstrated the challenges and benefits of implementing trauma-informed care into acute inpatient psychiatric units describing initiatives to attain that goal (Isobel & Edwards, 2017). A revisioning of acute inpatient care with trauma-informed care, which emphasizes strength building and skill acquisition rather than behavioural control, provides useful possibilities for the reduction in the negative impact of restrictive practices on patients and nurses. Changing care practices and associated culture on acute psychiatric inpatient units requires imagination, determination and commitment by individual health professionals as well as leaders of health services, in order to be successful and sustainable. To address this in part, The Australian College of Mental Health Nurses has recently been commissioned by the Australian National Mental Health Commission to undertake a project entitled “Safe in care, safe at work” which situates the safety of consumers and mental health nurses as central to the delivery of care in acute settings, where least restrictive care is facilitated. The project builds on the Supporting Mental Health Nurses towards cultural and clinical change: Facilitating ongoing reduction in seclusion and restraint in inpatient mental health settings in Australia project funded by the Commonwealth which I undertook with the college in 2017 (Muir-Cochrane et al., 2018; Gerace & Muir-Cochrane, 2018).This new project will develop a National framework for ensuring safety in care and safety for staff in Australian mental health services, reframing the policy narrative around seclusion and restraint reduction, to focus on ending fear and blame in mental health services and ensuring safety and improving quality at a national, state/territory and service level. It is anticipated that this work will indeed assist, at least in some part, in a revisioning of acute inpatient care and in a least restrictive, emotionally and physically safe environment.