Experiences And Perceptions In Adult Mental Health Care

Introduction

Physical restraints are any physical or mechanical devices adjacent or attached to one’s body and cannot easily be removed to restrict normal access and movement for patients (Barton-Gooden, Dawkins and Bennett, 2015). The use of physical restraints is dominant in psychiatric units, residential health centers and acute units. In the psychiatric units for mental health context, physical restraints are interventions used to maintain safety as last options for patients undergoing distress. They are mostly used to prevent and control violent behavior or give treatment for agitated patients in inpatient psychiatric units. Restraining uses designed instruments for example, belts (at the wrist, ankle, chest, or waist), bedrails and geriatric chairs with fixed tables or mitts among others. It is a common act in mental health practice where distressed behavior directly provokes practitioners’ responsibilities and accountabilities in balancing rights and well-being of individual patients and others. However, it is not a satisfying intervention because there is a gap in shared ethical decision making (Barton-Gooden, Dawkins and Bennett, 2015).

Tulchinsky, and Varavikova, (2009) suggest that day to day nurses make ethically informed decisions which is as a result of complex reasoning centered on experiences and knowledge that are driven by ethical values. In physical restraints, decision making is complex due to a number of factors. Lack of evidence to support its use, low availability of alternatives and negative concerns are some of the factors. According to research done between January 1990 and 2010, it was evident that nurses made decisions on patient restraints primarily focusing on safety. Though, thoughtful decision making of nurses comprises of a balance of a variety of choices with associated ethical values. Some nurse related aspects may hinder ethical decisions on physical restraints thus raising a concern in the need to educate nurses to come up with suitable decisions on physical restraints (Tulchinsky, and Varavikova, 2009).

Ethical Considerations in Physical Restraints in Adult Mental Health Care

According to Sturmey, (2015), the high rate of application of physical restraints in adult mental health services in the last two hundred years has seen a rise in the variety of ethical and clinical controversies. The last ten years has shown a steady rise of approximately 6% to 17% in the incident rate of physical restraints (Sturmey, 2015). Serious clinical and ethical issues that have been noted places blame on the local governmental authorities for compromising the basic rights of mentally ill patients. Ethical principles for the nursing practice are; principle of autonomy, beneficence, non-maleficence and the principle of justice (Sturmey, 2015).

Autonomous individuals make decisions according to their personal value (DeMarco, Jones and Daly, 2019). Therefore, to come up with informed consent it is basic for nurses to respect patient’s autonomy. Evidently, Barnes, Brannelly, Ward, L., and Ward, N. (2015) proclaim that restraining adults in mental health care institutions obstructs their freedom and such should be considered unlawful. Health practitioners are also considered obstructing autonomy when they proceed with restraining without the patient’s consent. Though, some conditions may not allow them to wait for patient’s consent especially when they are causing havoc to others. Therefore, with such it is posed as legal and efforts be made to let the parents or the next of kin is informed of the decisions made. Furthermore, according to the rules of Mental Health Commission (2009), physical restraints processes should be recorded in electronic media records. This is necessary to protect the staff from any legal actions due to unjustified compensations in case of adverse effects to the patient (Barnes, et al., 2015).

With regard to justice, all patients should be treated as sane in all circumstances (DeMarco, et al., 2019). Not even the mentally ill are denied their rights of patients for on occasion they depict normal conditions like any other. At times, physical restraints can be blindly imposed to aggressive patients resulting in the failure to understand patient in a humanly relationship. Apparently, making patients suffer prejudice and unfairness. While, in the nursing practice it is unavoidable to manage violent patients without physical restraint. Therefore, restrained patients are to be considered human with their basic needs attended to. They are to be subjected to rights of survival and equality and must not be treated unfairly. Mentally ill adults should be supported emotionally, treated with empathy to alleviate anxiety and depression after agitations. Proper psychological counselling is recommended in good time with quality care concerning bodily restraints they are subjected to (DeMarco, et al., 2019).

According to beneficence, it allows implementation of measures that benefit patients. Barnes, et al., (2015) states that there is selective beneficence in physical restraints that protects patients from physical injury. Health care practitioners are obliged to carefully render services that promote patient’s health. However, some extreme behaviors from emotional and cognitive malfunctions may place severe risks to patients themselves and others. Beneficence therefore allows for physical restraints as a measure for care and protection of patients. Ethically, beneficence conflicts with the autonomy of individuals to make decisions of what is to be done to them. Patients must be carefully supervised after restraints with close monitoring after about 4 hours since the medication takes effect after minutes, hours or even days. This is essential to ensure all observation in their change of state is noted and interest of patients is prioritized (Barnes, et al., 2015).

The principle of non-maleficence calls for health practitioners to do no harm (Foreman, Milisen, and Fulmer, 2010). It necessitates health care providers to equally balance goals of medication with their side effects. Nonetheless, it is obviously difficult to conduct some body restraints without physical injury and psychological trauma. Bodily effects are inclusive of skin injury with other damages like nerve system damage, pulmonary diseases and with adverse conditions like death. Psychological concerns are fear, anger, demoralization and loss of dignity. Generally, restraints reduce on their social function and intensify their depression and droopiness. Foreman, et al., (2010) assert that the goal of physical restraints should outweigh the adverse effects in nursing practice. Principles of beneficence and maleficence clearly should maximize benefits and minimize the detriments of physical restraints. Foreman et al., (2010) also purports that the principles and codes underlying physical restraints be clearly demonstrated for nursing practice supervision. Similarly, DeMarco, et al., (2019) elude that the main goal of restraining outweighs the side effects. They agree to staff training in aiding in reducing physical restraints in mental health settings. This is to make them conversant with the guideline, violence and to control their practice.

Experiences and Perceptions on Physical Restraints for Patients in Adult Mental Health Care in the United Kingdom

Studies have been conducted in the United States of America, France, Australia and the United Kingdom on experiences, perceptions and ways to manage aggression in physical restraints (Spandler, Anderson and Sapey, 2015). Spandler, Anderson and Sapey, (2015) came up with findings that health care providers in the United Kingdom struggle with managing violent behaviors from mentally ill adults in health care set ups. The National Institute for Health and Clinical Excellence (NICE) is the highest body in the United Kingdom for all clinical guidelines. It controls the management of short term violent behaviors in psychiatric settings. NICE once conducted a review in a mental health care setting and came up with guidelines on best clinical practices. Any deviation from it attracts validation (Spandler, Anderson and Sapey, 2015).

The use of restraints in adult mental health care setting for treating violent behavior has a long inconsistent history. Many times it has been significant in achieving its goal, but there have been no controlled studies to assess its value in the mental health care set ups (Elder, Evans and Nizette, 2011). Qualitative review reports have noted only extreme effects to the patients (Elder et al., 2011). According to Thornicroft, (2011), many studies indicate patients negatively agree to physical restraints. Restrictions used to manage patients may undermine their satisfaction and treatment adherence. Many feel shameful, helpless, humiliated and even traumatized. The patients at times can hardly relate why they are being set in seclusion and find it as punishment (Elder et al., 2011). Some even perceive it as a way to prevent them from interaction with others. More so, Thornicroft, (2011) posits that positive feelings have also been noted from physical restraints. Some patients feel a sense of security, some as part of treatment of their violent behavior. Therefore it is very important to find out individual patient perceptions in regards to physical restraining (Thornicroft, 2011). Physical restraints have also been found to have limited available information for health care providers on risk factors and hostile effects. There is also scarcity information on procedures that will lead to its reduced use (Thornicroft, (2011).

How to Minimize the Use of Physical Restraints for Adults in Mental Health Care Settings in the United Kingdom

There is a gap in the effectiveness and safety in the use of physical restraints in the United Kingdom (Richter and Whittington, 2006). Questions of ethical concerns in its application have resulted to its restriction by law in many countries. Health care authorities and nursing organizations have agreed to its reduction in mental health care settings. Numerous educational interventions that purpose to alleviate the use of patient restraints in mental facilities have been assessed (Richter and Whittington, 2006). Halter and Varcarolis, (2013) postulate that recent research in 2012 claimed inadequate evidence for the effectiveness of physical restraints but the research was questionable since two studies were left out in looking at its efficiency in long term care institutions. The studies strongly concentrated on change of policy in patient restraints by involving factors addressing organizational leadership. Irrefutably, inter professional collaboration, physicians, managers, health care professionals, relatives, patients and all other stakeholders are significant in minimizing the use of public restraints (Halter and Varcarolis, 2013).

Bleijlevens, Wagner, Capezuti, Hamers and International Physical Restraint Workgroup (2016) purports that interventions for averting and reducing use of physical restraints in mental health facilities targets to support health care practitioners to avoid using public restraints in their practice. However, Cleary and Prescott (2015) identified major barriers in reducing on the use of physical restraints. Some of them are attitudes from nurses, bad leadership and inter-personal network within the family and the health care providers and the belief that only physical restraining is the solution to help the patients avoid getting physical injuries from falls. The care givers consisting of the family and the nurses are always on the look of avoiding hazardous effects primarily focusing on public restraints as the easiest remedy (Cleary and Prescott, 2015). Consequently, this belief system and culture may result to physical restraints considered as the main strategy at the expense of many others. However, providing alternatives to the use of physical restraints may be a challenge too since there is a gap of knowledge in physical restraints alternatives (Bleijlevens et al., 2016).

Alternatively, interventions to physical restraints can be made basing on different categories of interventions. Halter and Varcarolis, (2013) came up with several interventions significant in reducing on patient restraints. For instance, use of belts can be replaced by sensor mats to reduce chances of falling or use of very low beds to reduce on injuries from falling. Health care personnel’s be well educated on public restraints. This will address the gap in knowledge of practitioners mostly on legal and ethical concerns (Bleijlevens et al., 2016). Multicomponent educational interventions are another aspect that looks at putting in place a least restraints and change the general culture of patient restraint use. They may be inclusive of technical devices to aim at alleviating risk factors and the use of patient restraints as one component (Bleijlevens et al., 2016).

In addition, health care providers are to be well trained in handling restraints of adults in mental health centers. Sometimes patients have recovered and would need someone that can easily identify and stop the use of restraints on them (Halter and Varcarolis, 2013). Training is also important in finding out emergencies and according proper assistance early enough to avoid distress that results to restraints. More so, family too can be trained to notice early indicators of relapse for appropriate reaction to avoid emergencies. Treatment on the other hand is administered at a local mental health care facility to enable the patients to maintain good contact with their families. After interventions, de-briefing and re-orienting of patients is important for their continued improvement (Halter and Varcarolis, 2013).

Conducting a study to find out the perceptions and experiences of adults in mental health facilities on physical restraints is essential to depict the right demography and provide medical progress on physical restraints. Physical restraints have been noted to have negative impacts to patients and its continued use may hinder recovery and rehabilitation. This therefore calls for nurses and all other health care givers to consider all the ethical principles and put them to practice. This also is to ensure physical restraints if considered are done in an ethical manner. Evidently, there is no quality organized review on the right interventions to prevent or reduce the use of physical restraints in adult mental cases in the United Kingdom. Results of such a study will be significant in clinical practice in adult mental health facilities. Data on effective interventions that can prevent or replace the use of physical restraints may result to promotion of care to the patients thus increasing the general quality of care.

Studies of psychiatric inpatients have cast light on manynegative and complex aspects entailed in the use of seclusion with or without restraint (SR). Many patients placed in seclusion are left with negative views of the event. Studies report feelings of anger and fear (Donat, 2002; Frueh et al., 2005; Kontio et al., 2012); the recalling of traumatic memories or of having ex- perienced trauma (Cano, Boyer, Garnier, Michel, & Belzeaux, 2011; Haw, Stubbs, Bickle, & Stewart, 2011); and feelings of abandonment and isolation (Bonner, Lowe, Rawcliffe, & Wellman, 2002; Holmes, Kennedy, & Perron, 2004; Lazarus, 2001; Mayers, Keet, Winkler, & Flisher, 2011; Paterson & Duxbury, 2007; Wilknis, Hunter, & Silverstein, 2004). Various studies also report an increase in violent acts and risk of injury for both patient and staff during SR episodes (Paterson & Duxbury, 2007; Weiss, Altimari, Blint, & Megan, 1998). As a result, over the past 20 years, legislation has been en- acted in different jurisdictions to establish practice guidelines for SR episodes. In Quebec, the Minist` ere de la Sant´ e et des

Services sociaux (MSSS) has asked health facilities to draw up procedures in accordance with the following principles: the measures must be exceptional, taken as a last resort, be the least restrictive possible, and be subject to monitoring (MSSS, 2002). Section 118.1 of the amended Act Respecting Health Services and Social Services provides a general definition of contro Studies of psychiatric inpatients have cast light on many negative and complex aspects entailed in the use of seclusion with or without restraint (SR). Many patients placed in seclusion are left with negative views of the event. Studies report feelings of anger and fear (Donat, 2002; Frueh et al., 2005; Kontio et al., 2012); the recalling of traumatic memories or of having ex- perienced trauma (Cano, Boyer, Garnier, Michel, & Belzeaux, 2011; Haw, Stubbs, Bickle, & Stewart, 2011); and feelings of abandonment and isolation (Bonner, Lowe, Rawcliffe, & Wellman, 2002; Holmes, Kennedy, & Perron, 2004; Lazarus, 2001; Mayers, Keet, Winkler, & Flisher, 2011; Paterson & Duxbury, 2007; Wilknis, Hunter, & Silverstein, 2004). Various studies also report an increase in violent acts and risk of injury for both patient and staff during SR episodes (Paterson & Duxbury, 2007; Weiss, Altimari, Blint, & Megan, 1998). As a result, over the past 20 years, legislation has been en- acted in different jurisdictions to establish practice guidelines for SR episodes. In Quebec, the Minist` ere de la Sant´ e et des

Services sociaux (MSSS) has asked health facilities to draw up procedures in accordance with the following principles: the measures must be exceptional, taken as a last resort, be the least restrictive possible, and be subject to monitoring (MSSS, 2002). Section 118.1 of the amended Act Respecting Health Services and Social Services provides a general definition of con

References

• Barnes, M., Brannelly, T., Ward, L., & Ward, N. (2015). Ethics of care: Critical advances in international perspective.
• Barton-Gooden, A., Dawkins, P. E., & Bennett, J. (2015). Physical Restraint Usage at a Teaching Hospital. (Clinical nursing research. Thousand Oaks, CA : Sage Periodicals Press Bleijlevens MH, Wagner LM, Capezuti E, Hamers JP, International Physical Restraint
• Workgroup (2016). Physical restraints: consensus of a research definition using a modified Delphi technique. Journal of the American Geriatrics Society, 2016. [Epub ahead of print].
• Billingsley, G., Losinski, M., Matson, L., Otten, K., Peterson, R. L., Rozalski, M., Ryan, J. B., ... Sutton, M. (2013). Physical restraint and seclusion in schools.
• Elder, R., Evans, K., & Nizette, D. (2011). Psychiatric & Mental Health Nursing - E-Book. Mosby Australia
• DeMarco, J. P., Jones, G. E., & Daly, B. J. (2019). Ethical & legal issues in nursing. Peterborough, Ontario : Broadview Press
• Foreman, M. D., Milisen, K., & Fulmer, T. T. (2010). Critical care nursing of older adults: Best practices. New York: Springer Pub. Co.
• Halter, M. J., & Varcarolis, E. M. (2013). Varcarolis' foundations of psychiatric mental health nursing: A clinical approach. Philadelphia, Pennsylvania : Saunders
• KK Cleary, K Prescott (2015).The use of physical restraints in acute and long‐term care: an updated review of the evidence, regulations, ethics, and legality. Journal of Acute Care Physical Therapy
• Richter, D., & Whittington, R. (2006). Violence in mental health settings: Causes, consequences, management. New York: Springer.
• Sturmey, P. (2015). Reducing restraint and restrictive behavior management practices. Retrieved from;- https://books.google.co.ke/books?isbn=3319175696. Cham : Springer.
• Spandler, H., Anderson, J., & Sapey, B. (2015). Madness, distress, and the politics of disablement. Bristol, UK : Policy Press
• Thornicroft, G. (2011). Oxford textbook of community mental health. Oxford [u.a.: Oxford Univ. Press.
• Tulchinsky, T. H., & Varavikova, E. (2009). The new public health. Amsterdam: Elsevier / Academic Press.