Handling and managing the mentally disabled patients has been a concern for the mental health staff for a long period of time, it has to be mentioned in this context that lack of mental stability and health is a considerable contributing factor to the irritability and agitation prone nature of the mental patient. Hence, as a result, managing the volatile mental health patients with altered behavioral patterns and response mechanism is one of the greatest professional challenge to the mental health workforce. As mentioned by Al-Khafaji, Loy and Kelly, (2014, the impact of this challenge also have been reported to act like a considerable barrier to their job satisfaction and professional growth, along with that, it also acts like a considerable cause for occupational stress for the mental health nurses.
Physical restraints had been in use for managing and containing patents with challenging behavioral issues and manic episode from a considerable amount of time. Especially for the patients with various degrees of psychosis exhibit extremely dynamic behavioral changes, and to contain them or calm them, physical restraints have been in use in clinical physiological practice. However, it has to be mentioned that it is an aversive practice and it is a violation of various ethical principle associated with a health care practice (Brophy, Roper, Hamilton, Tellez & McSherry, 2016). This assignment will attempt to critical review the available literature with respect to the use of physical restraints on mental patients in Australia, the ethical and moral issues, implications and impact on patients along with the practitioners engaging in the practice. For evaluating the literature selected, CASP tool will be used for the evaluation although each article will not be analyzed individually as per instructions.
Calming and containing the agitated and irritated patients has been the concern for the mental health nursing workforce for years. The behavioral changes in the mental health patients often tends to make these patients extremely irritated and agitated to very minor stimuli. Along with that, it has to be mentioned in this context as well that the impact of the harsh and sometimes even bullying experience encountered by the mental health patients also facilitates the uncontrollable manic episodes which are the most notable behavioral challenge experienced by the patients with psychosis symptoms. As a result, the use of physical restrains has come forward as the easiest and one of the safest techniques for the mental health workforce to calm and control the patients. As mentioned by Knox and Holloman (2012), the use of the physical restraints have been one of the greatest techniques for managing the mental patients with dynamic behavior and many have also considered restraints along with seclusion is one of the safest intervention to follow for the patients, especially for those with the high risk behavioral pattern. However, the use of the restraints is not just a violation to the moral and ethical principles of nursing or humanity, but many of the research studies have considered the use of physical restraints on patients as a major risk for injuring both the parties involved (Carroll & McSherry, 2015). Hence, it is very important for research studies to focus on the issues associated with use of physical restraints on the patients, the implications of this intervention and the patient and their families’ perception regarding the use of restraints in medical practice. Hence, this issue has been chosen for thus critical review of literature
Mental patient: Any individual suffering from ill mental health
Psychiatry: the division of clinical practice specializing in mental illness and the patients with il mental health
Physical restraints: any restrictive or restraining device used on the mental patients for physically restraining or containing them
Mental health: The complete health of the overall emotional, mental, and psychological state of the individual.
Music therapy: the therapeutic use of music as a mean to achieve care or intervention outcomes when used in health or social care setting.
For this critical review assignment the chosen database for conducting the research is SCOPUS, which is the largest abstract and citation database for peer reviewed literature articles. A great benefit for using this systematic article is the fact that while searching literature article from this database, there was no requirement for limiting the research specifically for the peer reviewed articles. The search terms that have been used for the critical review of the literature are “mental patients”, “physical restraints”, “restraints”, “Australia”, “psychiatry”, “inpatient setting”, “restraints and seclusion”, and “mental health nurses”. The initial search attempts discovered more than 100 results hence I had to utilize a few limiters such as time frame from 2012 onwards, English language, and full text article availability as limiters for the research study which helped me come down to ten relevant research articles. However, a grave requirement of this research study to include literature from the Australian demographics, hence in the next step of the research I had to utilize another additional limiter as a key phrase which is Australia to limit the number if results generated. Finally I could arrive at 5 relevant literature evidences which had reliable and authentic content which had been extremely relevant to the topic chosen by me for this assignment, hence, the critical review of the literature will also focus on the mentioned five Australia based research article.
The first theme that could have been generated from the research carried out for this paper indicated at the extent of use of the physical restraints for the mental health patients. The retrospective audit study carried out by Gerace, Pamungkas, Oster, Thomson and Muir-Cochrane (2014) has attempted to incorporate the data regarding the total usage of the restraints on the mental health patients, especially the emergency departments. The results of the study indicated that the rate of restraint use has decreased significantly in the past decade in different Australian regions, however, the use of the physical restraints is still prevailing. It has to be mentioned that the research aim had been clearly stated, although the research methodology and design had not been very clearly stated by the authors, which can lead to confusions for the readers (Khatib, Ibrahim & Roe, 2018). The data collection and analysis had been clear and succinct although the recruitment strategy could have been more elaborated. Regarding the research findings that have been illustrated the data detected a considerable amount of restraining however, the use of this aversive technique had been limited to 90% of the patients having a severe psychiatric diagnosis and compulsory hospitalization. The data had been extensively and explicitly illustrated including the use of soft shackle as the preferred mode of restraint and the median time utilized for the use of the restraints being 2 hours 5 minutes. Furthermore, the authors have also critically mentioned that there had been gender differences experienced in the data indicated female patients to be restrained more frequently although the restraining had been mostly due to preventing the likelihood of them causing any harm to themselves. The data triangulation had not been mentioned and the small sample size of the study can be considered key limitations of the study. however, further critically evaluating the article it has to be mentioned that the article has been able to provide key details regarding the use of restraints in the mental health facility scenario of Australia and especially in the emergency department and has also highlighted the gender differences prevailing in the scenario (Gerace, Pamungkas, Oster, Thomson & Muir-Cochrane, 2014). Hence, this can be fertile ground for further research to explore and understand the implications with clarity.
The article by Beghi, Peroni, Gabola, Rossetti and Cornaggia, 2013, has mentioned the prevalence as well as the risk factors associated with the use of different physical restraining methods have been identified by the authors in this article. The article has compared effectively the extent or prevalence rates of physical restraining on the psychiatry rates and Australia has been reported to have 11 % in the global context. The national comparison made in this systematic review article is a key contribution to the literature to better understand the impact of the restraint use and that the implications are. The research h aim, design and methodologies have been very clearly identified in the research which eases understanding of the claims. Regarding the data collection and analysis, not much details were provided by the authors, although the results or findings have been explicitly analyzed and illustrated by the authors. Exploring further, the key findings state that use of physical restraints is still widely in use in different developed nations including Australia and there is not much detail regarding the efficacy of the use restraint has not been critically addressed by the available literature, which indicates a key requirement for the need of more elaborate research on the existing evidence on this topic. A few risks that has been identified and discussed by the article includes that the use of restraints is higher in frequency on immigrants and asylum seekers in Australia (Beghi, Peroni, Gabola, Rossetti & Cornaggia, 2013). This can be considered as the most notable and novel addition to the available literature indicating the need for better human rights movement on the present discrimination faced mentally ill refugees and asylum seekers in Australia.
Another retrospective qualitative analysis study by Al-Khafaji, Loy and Kelly, 2014reports the perception of the mental patients regarding the use of restraints in the psychiatric emergency department and the implications of the use of restraints on the patients. The research aim and research design was illustrated by the author in a clear and concise manner which is commendable. The data collection and analysis is rigorous, extensive and explicit and have been mentioned with clarity in the article as well. With respect to the results of article, it has to be mentioned that the rate of restraint use in ED was less and 61% of the patients that were brought in did not require restraints. Although, the use of restraints was definitely in use for the rest (5 cases). A severe limitation of the study had been the fact that the study ED did not have a restraint log which restricted the data to be devoid of any bias. Along with that the article had been unable to include whether the chemical usage was associated with only sedation purposes or both for sedation and restraining (Al-Khafaji, Loy & Kelly, 2014).
Similarly the study by Brophy et al. (2016) states in their focus group analysis study that the impact of the restraining and seclusion is associated with severe negative outcomes for the mentally unstable patients focusing on 4 major Australian cities. The research aim and design again had been clear and concise for this particular study as well, however, there is very limited details mentioned regarding the data collection and analysis procedure other than the authors only mentioning the use of NVivo 10 qualitative data analysis software with a general inductive approach. Considering the explicit results illustrated by the article, the thematic analysis discovered that the use of restraints and seclusion had a direct implications associated with dehumanisation and ‘othering’, which ultimately led to anti-recovery for the patient. A novel initiative by the research study had been the input of the family and supporters negative and helpless perception to see their loved ones being subjected to restraining. However, it has to be mentioned that the focus groups have been very small which limited the generalizability of the findings. Along with that, the participation of the participants were limited to their opinions hence the chances of the data being biased is also high.
The brief narrative review by Romijn and Frederiks, (2012) discusses the reduction efforts being taken by the different nations including the Australia reviewing the recent literature. The study has clearly mentioned key aims, although the research design and methodology is not very clarifies in the article. The result findings are very concise yet explicit and very systematically arranged for better understanding. The findings state that Victoria is the first state to have legislative implications limiting the use of restrictions, and the aid of The Disability Act 2006 has also been a significant reform providing the mentally ill to have rights and needs. In terms of practice implications, the contribution of National Mental Health Consumer and Carer Forum (NMHCCF) and the Australasian Society for Intellectual Disability (ASID) along with Australian Psychological Society (APS) has been successful in developing a practice guideline limiting the use of restraints in psychiatric practice (Romijn & Frederiks, 2012). Although, there is need for more reform activities to improve the applications of this policy guidelines in practice.
As mentioned by Wilson, Rouse, Rae and Kar Ray (2018), the use of restraints have severe negative psychological implications associated the use of restraints on the mental patients and it has also been reported to threaten the chance and potential for the mental patients to have a significantly detrimental impact on the establishment of a therapeutic relationship and mutual respect between the mental patient and the health care provider as well. Hence, there is acute need for reducing the restraining practices so that the recovery potential of the mental patients can be improved and the negative impact of the restraint can be overcome with the optimistic efforts. A few practice recommendations that can help in reducing the practice associated with restraining is compassionate and engaging communication with the mentally ill. As mentioned by Papadopoulos et al. (2012), the impact of optimistic patient engaging and effective compassionate communication can calm the agitated mentally ill patients with aid of talk therapy. Another very promising intervention that can aid in reducing the rates of restraining is the music therapy which if employed effectively can easily eliminate the need of restraining for even risky behavioral patterns of psychotic patients.
According to Kontio et al. (2012), the restraining is a moral and ethical issue which not only impacts the recovery statistics of the patients, but can also impact the mental and emotional state of the care providers engaging in the restraining. Hence, there have been unrest and disinterest observed in the care providers as well and with proper policy implications, it can act like a protective factor for promoting the change. However, the lack of knowledge and awareness, lack of enough representation in the policy decision making and lack of training in the mental health staff in handling the mental patients can act as restrictive barriers to implementation of this change (Turner & Mooney, 2016).
Conclusion:
On a concluding note, the use of the physical restrain is undoubtedly a, extremely immoral and aversive act which not only impacts the health and welfare of the mental patient but it also impacts the overall welfare of the care provider as well. There are more risks than benefits associated with restraining a patient with behavioral instability and yet it is used as the most effective and safe intervention for calming the mental patients regardless of the negative implications on the both parties involved. This critical review had been successful in exploring the scenario of restraint use in all of Australia, the risks and benefits, implications on mental patients and their families and policy or legislative scenario. Hence, there is need for active efforts from both the government and the society or social activists to improve the scenario for the mental patients eliminating restraining with alternative beneficial alternatives mentioned in the recommendations.
References:
Al-Khafaji, K., Loy, J., & Kelly, A. M. (2014). Characteristics and outcome of patients brought to an emergency department by police under the provisions (Section 10) of the Mental Health Act in Victoria, Australia. International journal of law and psychiatry, 37(4), 415-419. Doi: 10.1016/j.ijlp.2014.02.013
Beghi, M., Peroni, F., Gabola, P., Rossetti, A., & Cornaggia, C. M. (2013). Prevalence and risk factors for the use of restraint in psychiatry: a systematic review. Rivista di psichiatria, 48(1), 10-22. Doi: 10.1708/1228.13611
Brophy, L. M., Roper, C. E., Hamilton, B. E., Tellez, J. J., & McSherry, B. M. (2016). Consumers and their supporters’ perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups. International journal of mental health systems, 10(1), 6. Doi: 10.1186/s13033-016-0038-x#Sec25
Carroll, A., & McSherry, B. (2015). Making defensible decisions in the era of recovery and rights. Australasian Psychiatry, 1039856215614987. Doi: 10.1177/1039856215614987
Gerace, A., Pamungkas, D. R., Oster, C., Thomson, D., & Muir-Cochrane, E. (2014). The use of restraint in four general hospital emergency departments in Australia. Australasian Psychiatry, 22(4), 366-369. Doi: 10.1177/1039856214534001
Khatib, A., Ibrahim, M., & Roe, D. (2018). Re-building Trust after Physical Restraint During Involuntary Psychiatric Hospitalization. Archives of psychiatric nursing. Doi: 10.1016/j.apnu.2018.01.003
Knox, D. K., & Holloman Jr, G. H. (2012). Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine, 13(1), 35. Doi: 10.5811/westjem.2011.9.6867
Knutzen, M., Bjørkly, S., Eidhammer, G., Lorentzen, S., Mjøsund, N. H., Opjordsmoen, S., … & Friis, S. (2013). Mechanical and pharmacological restraints in acute psychiatric wards—Why and how are they used?. Psychiatry research, 209(1), 91-97. Doi: 10.1016/j.psychres.2012.11.017
Kontio, R., Joffe, G., Putkonen, H., Kuosmanen, L., Hane, K., Holi, M., & Välimäki, M. (2012). Seclusion and restraint in psychiatry: patients’ experiences and practical suggestions on how to improve practices and use alternatives. Perspectives in psychiatric care, 48(1), 16-24. Doi: 10.1111/j.1744-6163.2010.00301.x
Papadopoulos, C., Ross, J., Stewart, D., Dack, C., James, K., & Bowers, L. (2012). The antecedents of violence and aggression within psychiatric in?patient settings. Acta Psychiatrica Scandinavica, 125(6), 425-439. Doi: 10.1111/j.1600-0447.2012.01827.x
Romijn, A., & Frederiks, B. J. (2012). Restriction on restraints in the care for people with intellectual disabilities in the Netherlands: Lessons learned from Australia, UK, and United States. Journal of Policy and Practice in Intellectual Disabilities, 9(2), 127-133. Doi: 10.1111/j.1741-1130.2012.00345.x
Turner, K. V., & Mooney, P. (2016). A comparison of seclusion rates between intellectual disability and non-intellectual disability services: the effect of gender and diagnosis. The Journal of Forensic Psychiatry & Psychology, 27(2), 265-280. Doi: 10.1111/j.1744-6163.2010.00301.x
Wilson, C., Rouse, L., Rae, S., & Kar Ray, M. (2018). Mental health inpatients’ and staff members’ suggestions for reducing physical restraint: A qualitative study. Journal of psychiatric and mental health nursing, 25(3), 188-200. Doi: 10.1111/jpm.12453
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