Despite guidelines recommending less coercive methods, physical restraint is still commonly used in many UK mental health settings.
In this article…
- The use of physical restraint in mental health settings;
- The effect of physical restraint on the nurse-patient therapeutic relationship;
- Using medication to manage violent and aggressive behavior;
- Using less coercive methods, such as advanced directives, to manage violent behavior in mental health settings
Authors Joy Duxbury is reader in mental health; Karen Wright is divisional leader for mental health; both at the School of Health, University of Central Lancashire
Duxbury J, Wright K. (2011) Should nurses restrain violent and aggressive patients? Nursing Times; 107: 9, early on-line publication.
Violent and aggressive behaviour towards nurses is common in healthcare, especially mental health settings. This article explores the value and safety of existing approaches to dealing with violence and aggression, including physical restraint and the use of medication. It highlights the need for greater preventative and participatory measures, and the use of less reactive strategies, such as advance directives.
Keywords: Physical restraint, Violence, Aggression, Mental health
This article has been double-blind peer reviewed
5 key points
1. A national audit of violence in mental health units found 73-86% of nurses have experienced violent and aggressive behavior
2. Physical restraint is still common in UK mental health settings despite a growing body of evidence recommending less coercive measures to manage violent and aggressive patients
3. Physical intervention can cause injuries to patients and staff, and can be highly distressing for patients, who often associate it with psychological trauma and loss of dignity
4. Restraint incidents are often followed by additional containment measures, such as psychotropic medication, which patients may see as controlling and coercive
5. Nurses should use advanced directives where possible to negotiate intervention strategies with patients to manage violent behaviour
Patient aggression in healthcare settings continues to be of concern, raising questions over the safety of both patients and staff. In 2005, the then Healthcare Commission published a national audit of violence based on 265 mental health and learning disability units in the UK. The audit found that violence against nursing staff was “consistently high” with up to 86% of nurses affected (Healthcare Commission, 2005). The National Institute for Mental Health in England (2004) and the National Institute for Health and Clinical Excellence (2005) have published guidelines on the prevention and management of violence in healthcare, highlighting safety priorities in mental health.
The guidance emphasises the importance of using preventative measures to manage violent behaviour, as well as employing strict guidelines to govern the use of physical restraint, which remains common in UK inpatient mental health settings (Richter and Whittington, 2006).
Violence and aggression
Violent and aggressive behaviour in patients can be influenced by environmental and contextual factors (Duxbury, 2002). Unclear policy and guidelines, overcrowding, poor ward design, inexperienced staff, poor staff retention, and poor information sharing all contribute to violent or aggressive behaviour (NICE, 2005; HCC, 2005)Studies have also shown a link between staff characteristics and the development of aggression and violence in mental health patients. These include negative interactional styles, provocative and authoritarian behaviour, and poor communication skills (Duxbury and Whittington, 2005; Glover, 2005). Reservations about using physical restraint to manage violent and aggressive behaviour are backed by a growing body of evidence suggesting restraint is associated with a number of adverse events, including death (Evans et al, 2002).
National guidance also identifies a number of factors that contribute to the use of physical restraint, including a lack of agreed standards, variations in practice, and a lack of staff knowledge and skills to prevent its use or identify alternatives (NICE, 2005)
NICE (2005) defines physical intervention as a “hands-on method of restraint involving trained designated healthcare professionals [aiming] to prevent individuals from harming themselves, endangering others or seriously compromising the therapeutic environment”. Physical restraint should only be used as a “last resort” to manage unwanted or harmful behaviours (NICE, 2005) but is used frequently in mental health services to manage aggression, damage to property or self-harm (Richter and Whittington, 2006). Physical intervention can cause injuries to patients and staff, and can be highly distressing for service users who often associate it with psychological trauma and loss of dignity (Chien and Lee, 2005). In extreme cases it has resulted in fatalities (see case study).
The inquiry into the death of David ‘Rocky’ Bennett highlighted the use of physical restraint. The 38-year-old African-Caribbean man died in 1998 after being restrained for 25 minutes by staff while an inpatient in a medium secure unit in Norfolk (Blofeld, 2004).
David, who had schizophrenia, had received care and treatment for 18 years at the time of his death. After repeatedly experiencing racial abuse and being involved in an aggressive incident he was moved to a different ward. While on this second ward he hit a nurse and was subsequently restrained; he was held in the prone position, face down on the floor and continued to struggle until he collapse and died, still in the restraint position. An inquiry was held and revealed that he had been given “heavy doses” of antipsychotic drugs to contain him.
The inquiry into his death led to 22 separate recommendations for practice, including calls for further research and a suggestion that some patients might benefit from a “drug-free holiday” in hospital. One of the most significant recommendations was a reduction in the time that any patient should be held in a prone position, that this is always dangerous and that if it is ever required then it should not exceed five minutes. Furthermore, staff should receive specialist training in control and restraint and a resuscitation trolley should be available. The use of a second opinion-approved doctor (SOAD), to review prescriptions was also recommended as good practice.
A Cochrane review found little evidence to support the efficacy of physical restraint as a containment strategy (Sailas and Fenton, 2000), and there is also evidence indicating that it can exacerbate the behaviour it is designed to control, worsening the therapeutic relationship between staff and patients (Duxbury, 2002).
Although nursing staff may endorse the use of restraint under certain conditions, many see it as an ethically problematic practice that has an untoward effect on patients (Paterson and Duxbury, 2007; Duxbury and Whittington, 2005). Huckshorn (2005) set out to eliminate physical restraint in American mental health settings using the Six Core Strategies framework (Box 1). This reduced the use of seclusion and restraint by 60-70% (LeBel and Goldstein, 2005); both the NIMH (2004) and NICE (2005) have identified restraint as one of four priorities requiring immediate national attention.
Box 1. Reducing restraint
The six core strategies framework for reducing physical restraint:
- Leadership toward organisational change;
- Using data to inform practice;
- Workforce development;
- Using prevention tools;
- Service user involvement;
- Post-incident debriefing and review.
Source: Huckshorn, 2005
Preserving the therapeutic relationship
Balancing the protection of staff and patients with the preservation of the therapeutic relationship can be a dilemma for nurses. Arguments for the continued use of restraint are based on concerns about safety and order, yet patients often enter services in acute distress and previous experience of restraint can make them fearful of admission (Bonner et al, 2002). The decision to restrain a patient is a difficult one for nurses, who have to consider risk management, cultural imbalances and the safety of all involved (Duxbury and Paterson, 2005).
Attitudes to the use of restraint vary; although research examining patients’ and nurses’ views is relatively scarce, research has shown that nurses have mixed feelings about using restrictive interventions (Duxbury and Whittington, 2005). It is not uncommon for patients to perceive these strategies as distressing or even punishment (Moran et al, 2009).
Duxbury (2000) argues that coercive interventions such as restraint can be used to deal with patients perceived as “difficult” in an untherapeutic way. However, there is increasing evidence of the effectiveness of preventing or de-escalating situations involving acutely aggressive or distressed patients without the need to use restraint or rapid tranquilisation (Busch, 2005). LeBel and Goldstein (2005) demonstrated that restraint can be substantially reduced without a corresponding increase in alternative methods of control, and without jeopardising the safety of staff or patients.
Restraint incidents are often followed by additional containment measures, such as seclusion or drug-induced sedation, commonly known as chemical restraint (Stewart et al, 2009). It has been argued that administering medication to control aggressive or harmful behaviour is in the patient’s best interests (Olsen, 2001), and seclusion and physical restraint can be avoided (Lind et al, 2004). However, there are concerns about the potential physical dangers associated with forced medication use, which can also be seen as controlling and coercive by patients. Nurses who use psychotropic medication for its sedative effect risk disabling and deskilling their patients, impairing their ability to find a personal resolution to conflict (Thapa et al, 2003).
The most common methods of medication administration are “as required” (prn) or rapid tranquillisation.
The NICE guideline on the short-term management of aggression and violence (2005) defines rapid tranquilisation (RT) as: “The use of medication to calm/lightly sedate the service user, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, and allowing comprehension and response to spoken messages throughout the intervention.”
The guideline says RT should only be used to manage high risk of imminent violence that has not responded to interpersonal interventions, and recommends using less coercive methods, such as verbal de-escalation, as a first line strategy (NICE, 2005).
Medications used for RT should be fast-acting with few side-effects, and oral preparations should be offered first, followed by parental preparations, which are usually given by intramuscular injection (NICE, 2005). There is no absolute agreement about which medications or doses should be used from the available benzodiazepines and antipsychotic drugs, but lorazepine is usually the drug of choice because it has a shorter half-life than diazepam. This limits accumulation of the drug, which can lead to over-sedation. Antipsychotics are also used, either alone or in combination with benzodiazepines, as the newer atypical antipsychotic formulas are known to cause fewer extra-pyramidal side-effects such as tremor, slurred speech, anxiety and distress.
As required medication
The use of as required or “prn” regimens of psychotropic medication for disturbed behaviour, distress or agitation is widespread in psychiatric units (Chakrabarti et al, 2010). According to Donat (2005), nurses are unnecessarily reliant on the use of prn medication regimens for behaviour management. McLaren et al (1990) found 23% of psychiatric inpatients received at least one prn dose of psychotropic medication during their stay, rising to 50% among those in secure psychiatric care. Additionally, Curtis and Capp (2003) found that almost 80% of patients received prn psychotropic medication over one month. The main reason for administration was agitation and most of the medication administration was initiated by nurses.
This method of prescribing allows nurses to administer medication rapidly in acute situations or at the patient’s request, but it can allow the administration of high or above recommended doses. It can also be seen as punitive or disempowering by patients, who already feel subservient to nursing and medical staff (Duxbury et al, 2010). This method of administration can cause staff to rely too heavily on pharmacological treatments, although this may also be due to the lack of techniques and strategies available for managing aggression (Thomas et al, 2006).
NICE (2005) identified advanced directives as a key priority for the management of aggression. An advanced directive is a statement of a patient’s treatment preferences should he or she lose the capacity to make treatment decisions in the future (Papageorgiou et al, 2002). Intervention strategies for the management of disturbed or violent behaviour should be negotiated with service users on admission to inpatient facilities, or as soon as possible thereafter. These strategies must be documented in the service users care plan and healthcare records.
Benefits of the successful implementation of advance directives include a positive therapeutic alliance, greater communication between staff and patients, continuity of care, and enhanced care planning (Papageorgiou et al, 2002). However, staff may be reluctant to use advance directives, patients may not understand them, and they may need to be overridden in some circumstances. It may also be inappropriate to use advance directives with some patients, and breaking the contract could harm the therapeutic relationship between the nurse and the patient. Additionally, a lack of evidence for the use and efficacy of advance directives can make their implementation difficult (NICE, 2005).
The aim of a post-incident review is to learn lessons, support staff and encourage the therapeutic relationship between staff and patients. NICE (2005) recommends conducting a review within 72 hours of the incident ending. The review should address what happened, including any trigger factors and each person’s role in the incident, and what can be done about it. Mental health service providers should have systems in place to ensure a range of post-incident support and review options are available, and that the review takes place within a culture of learning with appropriately trained staff.
Dealing with violence and aggression can be stressful for nurses, particularly if they feel inadequately trained to deal with it. The importance of understanding and addressing contextual and interpersonal factors that may contribute to aggressive behaviour cannot be underestimated, and most trusts now have policies and protocols in place to help staff deal with violent behaviour. With regard to the prevention and management of patients who are or may become aggressive, there is clearly a dichotomy of care; practitioners are required to balance the safety of staff and patients with a therapeutic philosophy of care.
In the light of the growing evidence base, a number of international organisations now consider physical restraint to be ethically unacceptable in all but the most extreme circumstances. The use of physical interventions to reactively manage aggression continues to come under scrutiny, but it seems we still have a lot to learn if we are to embrace the stance of least restrictiveness and only use physical restraint as a last resort.
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