The use of mechanical restraint in the management of psychiatric patients: Is it ever appropriate?

The management of violence in general psychiatry

There is increasing concern about the level of violence within mental healthcare settings. In this article I review what is known on this subject, discuss the relationship between mental disorder and violence and summarise the different ways to prevent and manage violence. When planning strategies to prevent violence in such settings it is important to consider not only patient risk factors but also risk factors in the environment. Staff need to have all the possible techniques for managing violent behaviour available to them in order to weigh up the risks and benefits for any specific patient in any particular situation.

Reduction of Physical Restraints in Residential Treatment Facilities

Children and adolescents with severe emotional and behavioral problems in residential settings can become so aggressive that physical restraints are utilized to keep them and others safe. Recently, the use of physical restraints in residential treatment facilities for school-aged children has come under increased scrutiny, and there have been legislative mandates that the use of physical restraints be reduced. This article describes a quasi-experimental field study conducted to examine the effectiveness of a 2-phase (organizational and milieu) physical restraint reduction intervention in a multisite residential treatment center. Results provide support for the effectiveness of organizational-level and milieu interventions for restraint reduction. Overall, restraint rates were reduced by 59% using these interventions.

Mechanical and pharmacological restraints in acute psychiatric wards--why and how are they used?

Restraint use has been reported to be common in acute psychiatry, but empirical research is scarce concerning why and how restraints are used. This study analysed data from patients' first episodes of restraint in three acute psychiatric wards during a 2-year study period. Logistic regression analyses were used to identify predictors for type and duration of restraint. The distribution of restraint categories for the 371 restrained patients was as follows: mechanical restraint, 47.2%; mechanical and pharmacological restraint together, 35.3%; and pharmacological restraint, 17.5%. The most commonly reported reason for restraint was assault (occurred or imminent). It increased the likelihood of resulting in concomitant pharmacological restraint. Female patients had shorter duration of mechanical restraint than men. Age above 49 and female gender increased the likelihood of pharmacological versus mechanical restraint, whereas being restrained due to assault weakened this association. Episodes with mechanical restraint and coinciding pharmacological restraint lasted longer than mechanical restraint used separately, and were less common among patients with a personality disorder. Diagnoses, age and reason for restraint independently increased the likelihood for being subjected to specific types of restraint. Female gender predicted type of restraint and duration of episodes.

The use of mechanical restraint in mental health: a catalyst for change?

The Care Quality Commission recently acknowledged the use of mechanical restraint/s as an intervention for the management of self-harm. I implemented the use of mechanical restraint for a female patient in life-threatening circumstances. This involved an exploration of the defining characteristics as well as the history and ethics of mechanical restraint. Informed consent and examining the legal, ethical and organizational frameworks supporting the use of this intervention in the clinical setting were critical to implementation. Ultimately the outcome not only proved to be life saving, but also a 'catalyst for change'.

Restraints and the code of ethics: An uneasy fit

This article examines the use of physical restraints through the four broad principles of ethics common to all helping professions. It asks whether the continued use of physical restraints is consistent with ethical practice through the lens of those principles. It also examines where the necessity to use restraints in the absence of empirically supported alternatives leaves professionals in terms of conflicts between ethical principles and makes recommendations for changes in education and clinical practice. It concludes that an analysis through a bioethics lens demonstrates that the use of restraints as a tool in psychiatric settings is a complex and multifaceted problem. Principles of ethics may often be in conflict with each other in instances where patients must be physically restrained.

Construction of an instrument to evaluate nurses' decision making in relation to the use of restraint in acute care psychiatry

Use of physical restraint in acute care psychiatry has been, and continues to be, a controversial issue. For this reason, a study was conducted in 1996 that examined nurses' decision making related to the use of physical restraint with aggressive psychiatric patients. An instrument, the Moylan Assessment of Progressive Aggression Tool (MAPAT), was developed for this purpose. Information relating to this instrument has not been previously published. It is currently in use in an ongoing research study by the author. A description of the process of the development of the MAPAT is provided here, along with the validity and reliability of the instrument, and implications for potential use in research, training, and education.