Alternatives to use of restraint: A path toward humanistic care.

Restraint and seclusion are measures to restrict the movement of a person. The predominant reason cited for the use of restraint in mental health settings is the safety of the staff and the patient in times of aggression and to control problem behaviors. However, there have been significant issues in terms of ethics, rights of the patient, and the harmful effects of restraint. Recently, there has been a move in Western countries to decrease its use by incorporating alternative methods and approaches. In India, the Mental Healthcare Act of 2017 advocates the use of least restrictive measures and alternatives to restraint in providing care and treatment for person with mental illness. In this context, approach to restraints is all the more relevant. This article looks to overview the types of restraints, complications of restraints, and the alternatives to restraint in diverse settings.

INTRODUCTION

Restraint is defined as any manual method, physical, material, or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body or head.[1] Fisher, in his review, concluded that restraint/seclusion is useful in controlling aggression and agitation in persons with severe mental illness and that this is one of the important tools in inpatient psychiatric settings.[2] Parallelly, he acknowledged that the process of secluding and restraining has adverse physical and psychological effects on both the patients and the nursing staff. Most studies following that have reported the adverse effects of restraint and have emphasized the need for less restrictive alternatives.

The Department of Health and Human Services document on restraint in the United States clearly outlines the rights of the patients with respect to the use of restraint. It states that seclusion or restraint be used only after the less restrictive means are not effective. To be free from seclusion/restraint is the right of the patient and these coercive measures are to be used only when there is a threat to the life of the patient or the treating staff.

TYPES OF RESTRAINTS

Literature explains different types of restraints, namely physical chemical, seclusion, and environmental.

Physical restraint can be defined as any device, material, or equipment attached to or placed near a person's body and which cannot be controlled or easily removed by the person and which deliberately prevents or is deliberately intended to prevent a person's free body movement to a position of choice and/or a person's normal access to their body parts.[345] The most common examples of physical restraint include bedside rails, tucking very tightly in sheets, limb ties, straps, belts.[36]

Chemical restraint is the use of medications which are not part of the patient's treatment regimen and are used solely with the purpose of restricting the patient's behavior.

Seclusion is a way of environmental restraint. Seclusion is defined as placing a person alone in an area with the doors shut in such a way as to prevent free exit from that area.

Environmental restraint is predominantly used to prevent free movement of a person in a building/area.

The predominant type of restraint that has been constantly discussed in the literature is mechanical and physical restraints. The practice of restraint and attempts to reduce its use by alternative methods have been attempted in various clinical settings such as (a) acute psychiatry ward,[47] (b) long stay homes for mentally retarded and patients suffering from severe and chronic mental illness, (c) child psychiatry wards,[8] and (d) elderly care nursing homes.[7] Restraint in acute psychiatry ward is predominantly used as a means to control aggression and in turn decrease the harm to self and others,[91011] whereas in child psychiatry wards and long-stay homes, it is used to control problem behaviors.[8] It is used in elderly nursing homes as a means to decrease the mobility of the patient so as to ease the process of care and to decrease the injuries to self.

RESTRAINT: WHY NOT?

The reason for the use of restraints being questioned is that the use of restraint and the antipsychotic sedative medications is one of the most common causes for human rights litigations in the US.[12] This is secondary to the negative impression created in the minds of the patients’ caregivers about the quality of the provided care during the process of restraint and forceful administration of sedative antipsychotics.[13] To add further, a large proportion of patients who have comorbid alcohol or drug use and comorbid medical conditions are more prone for injuries with restraint.[14] Another view is that the use of restraint or antipsychotic medications for challenging behaviors is less likely to impart any long-term benefits for such behaviors outside the settings of inpatient wards.[1516] Smith et al., in their paper on the use of restraint in self-injurious behaviors, noted that the use of restraint by staff could act as a negative reinforcer for the staff, where applying the restraint will decrease the aggression in the ward and hence the staff would use it more often.[17]

Consequences of restraint can be grouped into physical, psychological, and social. Much has been published about the physical consequences whereas little is known about psychological and social consequences.[4] Even those literature which speak about the restraint's ethical issues and considerations are predominantly about the ethical issues around the physical restraint. Use of restraints is further affected by differences in legislation, education, culture, and the settings in which such restraints are used.

Physical consequences of restraints are many. They include bruises, increased agitation, and increased mortality as a result of strangulation or as a consequence of serious injuries. In the elderly patients who are restrained, these are compounded with decubitus ulcers, respiratory complications, urinary incontinence, constipation, undernutrition, impaired muscle strength, and decreased cardiovascular endurance.[1819202122] A qualitative study which tried to understand the experience of being restrained found that the predominant feeling has been negative-psychological trauma, feeling of shame or guilt, loss of dignity and self-respect, and loss of autonomy.[23] For all the above-mentioned reasons, the regulatory agencies and the advocacy groups are pushing for measures to decrease the use of restraint.

DO WE HAVE ALTERNATIVES TO RESTRAINT?

Here are some suggestions for alternatives practices that can be used in different settings:

In elderly caring nursing homes, the restraint alternative guide issued by Ohio's quality improvement organization, the guidelines are predominantly around individualizing the care – it advocates regularization of activities, minimizing the changes in daily schedule, feeding regularly, easing the activities of daily living, and reducing pain as alternatives that can lead to reduced use of restraint in those with cognitive decline. It also focuses on the medications and their side effects as they can be a source of aggression and need for restraint.

Don William, in his review on recent research in eliminating and reducing physical restraint, mentions five distinct approaches: restraint fading, staff training, assessment and modification of antecedent conditions, modification of release criteria from restraint, and successful behavioral treatment.[24]

Restraint fading is a method that has been used by behavioral analysts over the last three decades, predominantly in people with developmental disabilities. It is used to manage self-injurious behaviors and to eliminate restraint and mechanical protective devices (for example, the effects of response effort on hand mouthing and adaptive behavior through advocacy of wearing arm sleeves). This reduces self-injurious behavior without having to resort to restrictive and violent coercive measures. Staff training is an organizational plan to reduce restraint uniformly, which has shown positive results consistently across studies.[25]

Some alternatives that can be considered in centers for long stay are assessed behavioral competencies of the caring staff at all levels. The need for behavioral observations is immense, as it will inform the ward staff and the treating doctor about the triggers for violence or aggression. Once the triggers are understood, violence or aggression would be easier to handle. Improving the behavioral competence of the staff is the next logical step. Training modules which impart skills and necessary background knowledge for assessing and implementing the behavioral management are available and have shown a significant difference in the need for restraint antipsychotic medications in the ward.[26]

When it comes to emergency psychiatry units and acute care wards, in a survey conducted by Downey et al.,[27] it was noted that about 90% of the emergency departments consider using an alternative before actually restraining. The most commonly used method is one-to-one verbal dialogue, followed by a time-out or pastoral care.[25] In one of the studies which examined the practice and opinions of practicing physicians and nurses from two psychiatric hospitals in Finland, most of the respondents agreed to using three common alternatives:[28]

Nursing interventions – The mere presence of the nursing staff round the clock and regular conversations with the patients will make the patients engaged and decrease the incidents of aggression

Multi-professional agreements involving patients – It was noted that agreements involving physicians, nursing staff, and the patients about the medications, dosage, difficulties in the ward, and criteria for restraint and seclusion will make the patient participate in the treatment process, and in turn, more co-operative and less aggressive

Use of authority/power, either in the form of strength of the ward staff or in the form of a person with authority, like a senior nurse or the physician – their presence or a conversation with them will help in controlling the aggression without the need for restraint.

In a recent randomized control trial in Finland by Putkonen et al.,[29] it was observed that a six-point approach consisting of improved leadership (behaviors conducive to producing safe environments include: being aware of consumer behaviors, attending to particular situations and the flow of activities around the ward, and caring for people and connecting with them); staff development (engaging with the patient, deciding when to intervene, ensuring safe conditions for de-escalation, and strategies for de-escalation); use of data (obtaining data on seclusion and restraint episodes for clinical, educational, and managerial purposes); consumer involvement (learning to respect consumers as people); use of seclusion-restraint tools (using assessment tools to facilitate the identification of stress triggers, early signs of distress, and calming strategies); and postevent analysis (information gathered from consumers, their families, and community nurses); and used to inform discussions during multidisciplinary meetings reduced the incidence of restraint and seclusion without increasing the violence in the psychiatric wards.[28]

A systematic review by Scalan pointed out seven strategies that are useful for reducing the use of restraint in inpatient settings.[30] These include (a) A state/authority/service level policy change to decrease the use of seclusion and restraint ensures commitment to and support for the efforts and usually turns into actions; (b) Staff and families can hold sessions in which they review the circumstances around seclusion/restraint and the methods/means, in which these can be prevented. Donat found that use of such committees decreased the incidents of seclusion/restraint by 34%;[31] (c) Collection and reporting of such incidents act as a feedback loop and in turn decrease the use of restraint; (d) Training the nursing staff on de-escalation and crisis management. Training to address the attitude and to debunk the myth that seclusion and restraint are interventions to promote safety and improve compliance is also of utmost importance; (e) Family/consumer can contribute to a reduction of restraint use by taking part in developing treatment plans and crisis management strategies and by being part of the process of review of precursors and outcomes of crises. Such involvement improves the compliance of the consumer and in turn decreases the acts of violence/aggression; (f) Increasing the staff ratio either for the ward or as part of crisis management teams, where staff from other wards help in the times of crisis. Increasing the staff ratio also increases the interaction between consumers and staff and contributes to a decline in seclusion or restraint. (g) Changes in the environment of the ward and units, such as reducing the ambient distress levels and changing the interaction style between the consumers and nursing staff can be helpful too.

Smith et al.,[32] in their article describing the methods implemented in Pennsylvania State Hospital, reported a decrease in not only the incidence of seclusion/restraint but also in the time duration in those who are restrained.[31] They reported a process of about 11 years, and it involved most of the above-discussed components – leadership to start the change, advocacy to decrease the use of restraint and seclusion, staff training (introduction of Psychiatry Emergency Response Teams), improving unit size, and optimizing patient to staff ratio and incident management systems.

In 2012, the American Association for Emergency Psychiatry Project Best practices in Evaluation and Treatment of Agitation (BETA) Seclusion and Restraint Work Group released a consensus statement.[33] “BETA” here stands for Best practices in Evaluation and Treatment of Agitation. The focus of project BETA is a noncoercive de-escalation to calm the patient so that he/she cooperates in the assessment and management of agitation or aggression. The guidelines state that if a person can be in a dialogue, then verbal de-escalation should be used. Patients differ in the need for medications. A few will regain control with decreased stimulation, and separating them in a seclusion room, with door unlocked, may give the patient enough opportunity to regain control. In those who can communicate, their preference for medication should be considered while giving the medications.[113435] Restraint should be used only if the patient is an imminent danger to others. All patients who are restrained should be monitored to assess the response to medications and the need for continuation of restraint/seclusion. Once the person regains control, restraint should be terminated and thorough evaluation should follow.

Methods for Verbal De-escalation – Literature shows ten domains of verbal de-escalation: (a) Respect the patient's and your personal space (Stay two arm distance away from patients); (b) Do not be provocative in interaction; (c) Establish verbal contract with patients; (d) Be concise and keep conversations simple; (e) Identify the needs and feelings of patients, allow them to ventilate, and be an empathic listener; (f) Be an active listener and convey that through verbal acknowledgment, conversation, and body language; (g) Agree or agree to disagree-Find something about the patient's position with which you can agree; (g) Lay down the law and set clear limits – establish basic working conditions in nonthreating manner and clearly inform about acceptable and nonacceptable behaviors; (h) Offer choices and optimism – Offer the choice of treatment and empower the right to choose the treatment (individual autonomy), and (i) Debrief the patient and staff to reduce coercive experiences and to restore the therapeutic relationship.[3637]

These guidelines are applicable for acute psychiatry inpatient settings and the emergency psychiatry settings.

In India, Mental Healthcare Act 2017 banned seclusion and chaining in any manner for a person with mental illness. The use of restraint is permitted by the act only in those situations in which one has to prevent immediate harm to the patient concerned or others. The use of restraint is to be authorized only by psychiatrists, with regular and frequent documented monitoring. The restraint use should be intimated to the nominated representative (NR) within a period of 24 h and concerned Board should be intimated monthly once about all instances of restraint use. All psychiatrists in India may have to undergo training in the use of nonrestraint measures and least coercive measures in patient care.[1138] A national guideline about using the alternatives first and using the restraint only as a last means needs to be developed at the earliest.

CONCLUSION

The concept around seclusion and restraint has changed from that of one which is in the interest of the aggressive and agitated patient and the security of the staff to a more negative event which will leave behind physical and psychological injuries. Over time, it is clearer that these coercive practices will leave physicians and health-care professionals liable legally and financially. Use of alternatives to restraint is needed to improve the quality of care. These can be implemented only with the parallel implementation of various strategies in the wards, such as a change in the policy of the hospitals, training the staff, and imparting the necessary skills to handle the crises, development of crisis management teams, and a periodic review that includes inputs from the consumers and the careers. What is more striking is that little is being talked about the issues of restraint and other coercive measures in low- and middle-income countries compared to high-income countries. The reports from such centers are sparse, and there is an immediate need to assess the usage of, and the feasibility of applying, strategies found effective in the developed world in the developing nations.

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Conflicts of interest

There are no conflicts of interest.